Family Practice Vol. 20, No. 2, 185-191
© Oxford University Press 2003
Education in Primary Care |
Working with Bangladeshi patients in Britain: perspectives from Primary Health Care
Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Maelfa, Llanedeyrn, Cardiff CF23 9PN and
a Cardiff Bangladeshi Project, Cardiff Local Health Group, Trenewydd House, Fairwater Road, Cardiff, UK.
Correspondence to Dr K Hawthorne; E-mail: seysdene{at}aol.com
Hawthorne K, Rahman J and Pill R. Working with Bangladeshi patients in Britain: perspectives from Primary Health Care. Family Practice 2003; 20: 185–191.
Received 2 May 2002; Revised 6 September 2002; Accepted 4 November 2002.
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Abstract |
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Background. The difficulties of ethnic minority communities in accessing appropriate primary care are well documented, but little is known about the experiences of Primary Health Care Teams (PHCTs) serving these communities, or their strategies to help patients overcome these difficulties.
Objective. The purpose of the study was to explore the PHCT perspective of working with Bangladeshi patients.
Methods. Qualitative group discussions with PHCTs were set up by four health centres in the Grangetown area of Cardiff, where a large proportion of the Bangladeshi community lives. Experiences of and attitudes to working with Bangladeshi patients were explored. Discussions were taped and transcribed for independent analysis by two researchers. Comparisons within and between PHCTs were made.
Results. PHCTs largely entered into full and frank discussions. Health visitors had made significantly more effort than others to get to know their Bangladeshi patients. This had costs in terms of time and effort, with no reduction in caseload. Cutting across this difference were common themes such as communication and cultural differences, and patients’ difficulties in using NHS services appropriately, which caused disruption and frustration. While there was an awareness of the reasons for these difficulties, PHCTs generally were not able to allow for them because of the inflexibility of their workload and systems of working.
Conclusions. Group discussions are a useful way to encourage PHCTs to reflect on their practice and share experiences. PHCTs are aware of their patients’ needs and keen to explore racial awareness training and new ways of looking at how they work. However, the grind of heavy workloads makes this process unlikely without outside facilitation.
Keywords. Ethnic minorities, opinions, Primary Health Care Teams.
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Introduction |
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Numerous inner city practices in Britain have sizeable numbers of patients from ethnic minority communities. The burden of illness in many of these communities is high, due largely to the effects of poverty on health and the higher prevalence of chronic diseases (Box 1
).1,2 This study arose from initial exploratory work for a larger study designed to develop a responsive health education programme to meet the needs of the Bangladeshi community in Cardiff, as we felt that the development process would be usefully informed by a profile of Primary Health Care Teams’ (PHCTs) perspectives of the subject. | BOX 1 The nature of the challenge It is known that Bangladeshi men are at significantly higher risk from some of the major causes of mortality in this country compared with the indigenous white population.1 Overall mortality is higher (SMR 118, 95% CI 111–126), and mortality from diabetes (SMR 685, 95% CI 529–874), coronary heart disease (SMR 148, 95% CI 134–163) and cerebrovascular disease (SMR 254, 95% CI 222–319) is greater than for the general population, indicating a considerable health problem both now and for the future as this (largely) young community ages. In addition, there are well documented reports of difficulties faced by immigrants using preventive and screening services such as antenatal clinics and breast screening clinics,11–13 and in using general medical services10 (including, for example, increased attendance at GP surgeries14,15). Some of these differences stem from incomplete information both on the part of the health services (e.g. wrong address information leads to a proportion of invitations for screening being missed) and on the part of patients who cannot communicate, and do not understand appointment systems or how to use the services to their best advantage. Working restaurant hours makes it difficult for some to make morning surgery appointments. In addition, the lack of language (and sometimes reading) ability means that patients miss out on sophisticated information that they would otherwise find useful in the prevention and management of chronic disease, such as the role of podiatry and retinal screening in preventing diabetic complications.16–18
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While there is a growing literature on the views and problems of ethnic minority patients in the health care system,3–5 a systematic literature search of the databases Medline, CINAHL (Cumulative Index to Nursing and Allied Health), EMBASE, HealthSTAR and Premedline has found very little about the attitudes and experiences of the PHCTs that serve them, their perceptions of the difficulties posed by difference in language and culture, and the strategies adopted to deal with them.6–8 There is some work suggesting that GPs tend to hold negative attitudes towards people of South Asian origin, believing that they consult frequently with trivial complaints and are less compliant with medication.9 However, ethnic minority respondents in the Fourth National Survey were, if anything, less likely than whites to be admitted to hospital.10 There is a clear need to look at ways in which the whole PHCT deals with this perceived demand, in the context of well described increased morbidity and mortality.
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Methods |
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Participants and recruitment
The local Bangladeshi population numbers
5000 (1991 Census figures for Cardiff, HMSO), many of whom are registered with the four practices sited in the Grangetown area of Cardiff where they live. They mostly originate from the Sylhet district of Bangladesh, and are employed largely in the restaurant trade in Cardiff and its surrounds. A high proportion of adults >40 years (30% in our experience) are illiterate and/or unable to speak English. All four practices have South Asian GPs, one of whom speaks Bengali. The area is economically deprived, with an unemployment rate of 23% and an SMR of 130 (cf. 103 for Cardiff as a whole). There is a local community linkworker service—currently linkworkers act as interpreters in community care, work part-time and need to be booked in advance.
Table 1 shows the distribution of staff and their ethnic origins in the practices involved. (Our group discussions were not true focus groups in that participants knew each other.) One practice operated an open access appointment system.
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The discussion format was a novel experience for the participants as none of these practices held regular PHCT meetings. All arrangements were made by the practices themselves who invited those they defined as belonging to the team. Practices 3 and 4, which were sited in the same building, chose to have a combined meeting since they shared district nurses, health visitors and midwives. The meetings were tape recorded with consent for later transcription and analysis.
Process
Certain working assumptions from conversations in the recruitment phase were made about PHCT experiences in preparation of the areas for discussion (KH initially was commissioned by one of the practices to help with developing culturally appropriate diabetes education for Bangladeshi patients). It was assumed that team members would know little about the lifestyle and needs of the Bangladeshi community, and would have communication difficulties. In order to involve the whole PHCT in the discussion, a systematic approach to questioning about contact with patients was adopted. Antenatal and baby clinics, diabetes and heart disease clinics, appointments and bookings, cervical screening and home visits were all discussed specifically. In order to bring out positive experiences with patients (the tendency is always to think of problems), groups were also asked for examples of advantages of working with this community. We used two moderators: one supervised the tape recorder and kept the discussion along the pre-agreed agenda (JR); the other, an independent GP (KH), ensured that all sections of the group contributed equally.
Towards the end of each meeting, five closed statements were presented to the group for comment, stating that these were not necessarily the opinions of the researchers (Box 2). These were statements originating from preliminary discussions with key figures in the teams. The aim was to provoke comment to compare with the ongoing discussion.
BOX 2 Closed statements used in focus group discussions to assess consensus opinion in the PHCT
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Transcripts of the recorded discussions were read through independently and systematically by two researchers (KH and RP), and coded to identify emergent themes. Examples to illustrate these were noted, with connections that linked these categories together. Comparisons between and within PHCTs were made, and any special comments that were particularly pertinent or contradictory to the general themes developed by the rest of the participants were identified. The findings were fed back to the PHCTs involved and to wider local GP meetings to check agreement and generate further discussion.
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Results |
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Attendance and participation
All group meetings were well represented by the whole spectrum of their PHCT (Table 1
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Major themes
The most striking aspect of the transcripts was the difference in approach to ethnic minority groups shown by health visitors (HVs) (whose main body of work consists of communication in the home environment) compared with other professionals. Cutting across this difference were common themes such as communication and cultural differences, patients’ difficulties in using NHS systems appropriately, and awareness of the reasons for these difficulties.
Patients in a surgery setting.. From the first contact, staff had difficulties identifying and communicating with Bangladeshi patients. Only Asian staff members could identify them, using indicators such as language, dress, facial appearance, and differences in skin tone and stature. Despite not being Bengali/Sylheti speakers, other South Asian staff members were called on to help with communication difficulties and talked in group discussions as if they had an affinity with these patients (which they had to some degree, in terms of a shared religion and some cultural mores). White receptionists felt that knowing a patient was Bangladeshi was unimportant to their work. As the doctors’ employees, they were caught between a rigid appointment system and patients who kept ‘restaurant hours’ (i.e. working late into the night and rising late in the morning) wanting to see the doctor at ‘inappropriate’ times. Receptionists in Practices 1, 3 and 4 felt patients sometimes misused the system wilfully, using their lack of understanding as an excuse. Although understanding the reasons for ‘emergency’ appointments, lack of time as well as language difficulties made it hard to deal with patients diplomatically. There was concern expressed in Practice 1 that patients refused such access might feel they were being discriminated against, although no such accusations had been made.
Doctors also found this frustrating: "they need to understand that they get best treatment if they present at the best time . . . they do not understand how it (the NHS) is organized and how they should interact with it . . . they expect us to accommodate" said a doctor from Practice 1. The only suggested solution was that patients should change and needed education to do so. Practice 2 held both open and appointment-only surgeries; they reported less conflict and, because they had a Sylheti-speaking receptionist, said they managed to make themselves understood and that patients did not abuse the system.
Where language differences were a problem, receptionists and doctors would use other receptionists, children, spouses or other patients from the waiting room. Two practices had receptionists from the Sylheti community, one had an Urdu-speaking receptionist, who had a few Hindi words in common with Bengali. The teams agreed that using such means to communicate was acceptable for administrative tasks, but not for passing on clinical information. However, it still happened because there was no alternative. No-one mentioned concerns about breeches of patient confidentiality.
White doctors and nurses said they had an impossible task to engage patients, build up the doctor–patient relationship and explain complex clinical concepts. One doctor said that because of this, she could not feel confident in a Bangladeshi mother’s ability to deal with sick babies and was therefore more likely to admit them. She felt helpless with diabetic patients . . . "we just smile at each other."
A district nurse from Practice 1 sensed that they were relatively unaware of cross-cultural non-verbal cues "With an English lady, if she is becoming overstressed I can see it. With an Asian lady she had to be breaking down in tears before I realized something was happening". Sometimes, even when non-verbal cues were picked up, they could not be used due to the patient’s contextual situation. "They come in and you know full well they’ve got depression or they’ve got marital problems . . . The husband’s there, the children there and there is no way you can deal with the problem" said a doctor from Practice 1. The doctor’s reasoning for the conflict was in terms of "the culture of poverty, the culture of different religious beliefs, and people transplanted from the Third World to a Western setting." This apparent interplay of cultural and language barriers made some women inaccessible. A health visitor said later "you say to the wife, are you well? . . . he (the husband) says yes she does. He doesn’t even ask her, he doesn’t even interpret what I’m trying to say to her and I don’t think women are allowed to say they feel ill or they feel poorly because, they’ve just got to get on with everything anyway." She continued: "some families . . . the husband actually times the wife taking the children to school. If they are out any longer he wants to know where they’ve been and who they’ve been talking to. I mean that’s not every family but some families are like that . . . I say to them, why don’t you learn English, why don’t you go shopping and they say my husband won’t let me." The South Asian doctors in Practices 3 and 4 voiced the opinion that women were not allowed to think for themselves, but added: "In some cases, I think there is an education problem as well . . . they have to be dependent on somebody who might take the responsibility. They won’t understand sometimes even when you explain." However some of the reticence could be due to cultural barriers talking to a ‘strange’ man: "It’s not because she doesn’t understand you because she answers to the child."
Patients at home.. A large proportion of an HV’s work takes place at home, and they had made considerable efforts to understand the needs and lifestyles of the families they visited. They used a linkworker on a regular basis, but were then limited to visiting at mutually convenient times. This was time consuming, the consultations took longer because of the interpreting and explanation necessary, and patients would keep them waiting while they dressed or tidied up upstairs. There was no provision for a reduction in their caseload to compensate for this, and they felt stressed as a result. They said the linkworker was a ‘huge benefit’, both in ice breaking and in translation. Some women chose to talk through an intermediary initially even if they did not need one. One HV cited a number of instances when she later found mothers quite able to understand and communicate, albeit in broken English.
Because they had spent time in ‘quality’ communication with patients and their families, HVs had learnt a lot about their lifestyles, cultural rules and priorities, and respected them. They understood why early morning calls were unwelcome to someone keeping restaurant hours, why young mothers could not come on their own to Baby Clinics, and some of the pressures they faced both from inside the family as well as the outside disadvantage of looking and dressing differently and being unable to speak or read English. They found themselves naturally supportive of women and their situation but critical of male cultural mores that affected women’s behaviour. The group discussions were peppered with their defence of patients whenever someone said anything critical, and they could make allowances for ‘bad’ behaviour such as lateness for appointments. One said "I tend to visit either late morning or in the afternoon when I know that they are all going to be up but, they do have a problem with their timekeeping . . . I don’t think they realize that it is important."
GPs found this approach very inconvenient and used their authority to hurry along consultations. The Practice 4 doctor said "When I go, they say have a seat in the front room. I say look, I haven’t got time, I will go upstairs. The reason is . . . they have not got much room, father and mother and four children in one room . . . they don’t want you to see how they are living or whatever the situation is."
Patient beliefs and expectations.. No members of the PHCT had found real conflict with traditional health beliefs. Indeed, patients generally were willing to accept Western health belief models, especially with regard to dietary advice for diabetes and advice on infant-rearing methods. Where patients were non-compliant, the reasons for this appeared to be due to other social or family pressures, or not perceiving the importance of the recommended health behaviour to future good health. (This finding agrees with work from Glasgow19.) One HV said "The families that I go to see are quite happy for me to see them, I could go every day and they would welcome me with open arms but, they won’t come to the clinic. Some of it may be because the husbands won’t allow them out of the house." Practice nurses had had similar experiences. One said "I ask them why didn’t you come? ‘My husband went to London and I couldn’t make it’ . . . I say why didn’t you come for the diabetes monitoring. ‘Oh I didn’t think it was necessary’."
Practice 1 employs a nurse practitioner to triage and treat minor illnesses. Bangladeshi patients were reluctant to see her because she was not a doctor and could not prescribe. Doctors agreed that patients wanted tangible treatment. One doctor said "but some, sort of middle age to older group . . . they think they should have something whether it’ll work or not. They wouldn’t go home empty handed." Paradoxically, some receptionists pointed out to the doctors that, while wanting a prescription, some patients did not seem to know how to take it.
Practice nurses in three of the practices felt their patients expected a cure for diabetes. There was a consensus opinion that patients did not take responsibility for managing their diabetes, with one nurse commenting "they just bury their heads in the sand because its not something you can actually see and they think its either going to go away or it doesn’t matter." GPs felt patients were not prepared to change lifestyle habits: "You can’t improve their behaviour . . . because they don’t want to change it. For them diabetes is avoiding sugar only. And they don’t like to do exercise."
Racial awareness training.. One HV had attended a course on racial awareness, although many participants felt it was needed. There was general agreement that they knew little about the community, its beliefs, diet or culture. The nurse practitioner said "I also feel in their defence it is partly because we fail to understand. I think I would be helped in what I’m doing by understanding the culture better. For instance, I have no concept of the diet at all. I do try and find that out from the patients but because of the language its difficult."
Degree of consensus with statements (Box 2)..
All four PHCTs agreed that Bangladeshi patients frequently tried to fit more than one person into an appointment, disregarding appointment systems if they were present. However, they were no different from other patients in wanting letters for housing or sick notes. There were varied opinions on whether the Bangladeshi extended family was supportive. One practice felt it was detrimental to women, although men would be well looked after. The two Bangladeshi receptionists felt unhappy with statement 4, and insisted that the barriers for women had become much less and that women were more assertive today.
Statement 5 had a mixed reception. Most of the illness presenting was thought to be trivial (nearly all staff said this, including the receptionists), although one doctor (Practice 1) and the HVs had noticed that there was a high prevalence of chronic disease. Others said they were just like anyone else and should receive the same treatment. HVs were more aware of psychological problems but said patients were unable to talk about them openly as there was huge stigma attached to mental illness. The Asian doctors concurred—they felt patients were unlikely to seek help from them7 and said that the Asian community was supported by the extended family system, which prevented people from getting lonely. Practices 3 and 4 claimed that they had hardly any Asian patients on antidepressants.
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Discussion |
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This study gives some insight into the issues and experiences PHCTs face when engaging with Bangladeshi patients. Many of the issues raised and discussed in this paper are applicable to PHCTs both in the UK and elsewhere in the world, where they work with people from cultures and backgrounds that are not their own. This method illustrates how a qualitative approach can be used in a non-threatening environment to explore what PHCT members think about their ethnic minority patients, their definitions of the problems of delivering care, the reasoning behind the opinions voiced, and their readiness to adapt their own systems and practice. It also shows the importance of the organization and context of primary care work in shaping dominant views and concerns.
The findings were limited by the pragmatic methodology chosen, since it was part of a larger project set up to develop culturally appropriate health education for the Bangladeshi community. Although we have tried to describe the composition of the groups (Table 1), we are aware that we did not enquire into individuals’ detailed cultural, class, educational or religious backgrounds (this also includes the South Asian participants). These attributes might have affected their attitudes towards Bangladeshi patients (who could be seen by some as poor, uneducated and from a ‘rural’ part of Bangladesh), to women and their position in society, and to the partly hidden mental health problems in the community. The composition of the group discussions also meant that there were potential conflicts of interest, since members knew each other well, PHCTs are hierarchical in nature and some participants were in the employment of the GPs present. This could have resulted in people choosing not to criticize the way their GPs handled the administrative problems resulting from communication difficulties with patients. Finally, asking about experiences with ethnic minority communities is itself risky, since participants might be afraid that if they expressed negative views, this might be inadvertently construed as racism or discrimination. Despite being aware of these possibilities, we chose this method because we wanted these discussions to be a springboard for PHCT development in this arena; these teams have to work together in real life to deliver a service to patients, and we wanted to observe their ability to communicate, share ideas and work together. Even though some of the organization was dictated by the GPs present in discussions, participants were surprisingly frank about the problems this caused them in their dealings with Bangladeshi patients. Practice 2 was the only one that caused some doubts about the reliability of their data, largely by virtue of what was left unsaid in comparison with the other three practices. This practice gave us the overall message that there were no particular problems with Bangladeshi patients, that it operated on the principle that everyone should be treated equally, and that the problems described by other practices were overcome by ‘gentle persuasion’. However, it also differed from the others in that it employed a Sylheti/Bengali-speaking receptionist and operated an open appointment system. Without getting deeper into this practice’s transactions, it is not possible to judge whether it had really found a solution, or was ‘playing safe’ in the discussion.
It is clear that staff have difficulty communicating with patients from their appearance at the reception desk to detailed clinical consultations in the surgery or at home. Respecting confidentiality in these situations can be overlooked in the struggle to communicate. Intimate or emotive issues cannot be broached, and much is left unsaid. All members of the PHCT have, on occasion, felt frustrated, angry or helpless. An interview study of hospital nurses’ experiences with ethnic minority patients found many of the same problems, resulting in a lack of holistic care and an inability to develop a relationship with patients.6 Negative feelings were not only aimed at patients—much of the frustration was caused by primary care systems being too rigid to comply with patient need. Those group members who had come to know patients individually expressed respect for their cultural beliefs, lifestyle and the way they handled what were often difficult living conditions. Economically deprived, high demand young families are not unique to ethnic minorities, but the additional communication and cultural aspects add an extra dimension to the approach needed. The effort required to respond with sensitivity results in additional workload, as the HVs’ experience shows. In some cases, particularly mental health issues, the barriers put up by patients or their situations add to this difficulty. It may be that sometimes patients do not consider it appropriate to discuss these problems with a health professional.7
Why is it that practices do not alter their arrangements to fit in with the needs of local communities despite knowing the reasons for these needs? Receptionists felt caught between their employers’ insistence on appointment systems and patients’ demand for access to a doctor at their convenience. Meanwhile, the doctors continued to work as they had always done, unwilling to alter their working practices, with heavy workloads and little time for reflection or discussion with their peers. One doctor from Practice 1 pointed out that surgery working hours fitted in with those in secondary care that impinged on the surgery—collection of blood samples, ease of access for routine and semi-urgent enquiries and investigative tests. Altering the routine to fit in with patients would make the communication with secondary care disjointed, as requests would have to wait until the next day. The benefits of setting up a specialist health promotion/education/screening clinic20 for specific communities have to be offset against their costs in terms of time, effort and employing an extra member of staff, and the PHCTs in this study served a number of different ethnic minority communities, as is the case for many inner city practices.
Our findings have been fed back to the participating teams and to local GP educational meetings—these meetings agreed with the findings and conclusions. While these are major challenges, PHCTs have some responsibility to respond to them and seek support to identify and meet them. This will need additional manpower as well as a readiness to consider change, while also informing patients how to get the best from the system. PHCTs involved in this study are now requesting racial awareness training. This training should emphasize ‘generic’ approaches to ethnic minority patients, e.g. teamwork could result in receptionists asking patients what languages they speak so that arrangements can be made in advance for linkworkers to attend subsequent appointments. Knowing the prevalent languages in an area would also allow notices and posters to be prepared appropriately. Practices may need to give some consideration to altering surgery times and appointment systems to fit in with patients’ ‘restaurant hours’, trading off the change to their working arrangements against easier relationships with patients. Where feasible, PHCTs need to consider employing staff with local language skills, and ways of working more closely with the local multi-cultural health unit that supplies trained bilingual linkworkers. Rather than looking for a ‘cookbook’ exposition of different ethnic minorities’ cultural, dietary and religious habits, racial awareness training should be able to help these PHCTs to develop new strategies and consider the merits of other team members’ solutions.
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