Evaluation of the Medical Interpreter and Patient Guidance Training in the Migrant Health Services: The Case Study in Turkey

Introduction

Turkey is a country that embraces many migrants from Africa and the Middle East especially in the last 10 years due to its geopolitical position. After the Arab Spring uprising, Syria descended into a civil war in 2011. As the Syria crisis enters its ninth year, the magnitude of human suffering remains overwhelming, with 11.7 million people, including 6 million children, in need of humanitarian assistance. Up to 6.2 million people have fled their homes inside Syria and 5.6 million have been forced to take refuge in neighbouring countries. Without a political solution in sight, the conflict is likely to persist in 2019. The EU and its Member States have mobilised almost €17 billion inside the country and in neighbouring countries since the start of the conflict. According to European Commission data, the Syrian refugees migrated the most to Turkey, Jordan, Lebanon and Egypt. Turkey is currently hosting the largest number of refugees worldwide, with more than 3.6 million registered Syrians (https://multeciler.org.tr/turkiyedeki-suriyeli-sayisi/). A limited number of refugees are living in camps settled around the border, and others are spread throughout Turkey (European Commission, 2019). In particular, benefiting from the most basic human rights such as nutrition, education and health of migrants is an issue given the importance by the Republic of Turkey. For example, until 2016, about 21 million outpatient clinics, 1 million clinics, 184.390 births and 797.450 surgical services have been performed within the scope of health services provided to Syrian foreigners under temporary protection (http://www.goc.gov.tr/files/files/2016_yiik_goc_raporu_haziran.pdf).

This explosive and unexpected increase in the Syrian population in Turkey has had several negative impacts on health and social determinants (Doğanay and Demiraslan, 2016). In addition to these challenges to the Turkish healthcare system, Turkish healthcare providers currently have a large number of Syrian refugee patients with whom they have difficulty communicating because of language barriers (Doğanay and Demiraslan, 2016).

Only a minority of refugees speak Turkish before arriving. The inability to communicate fluently was a barrier, not only to integration, but also in managing the asylum process necessary to gain full access to the healthcare system. Language barriers also often present obstacles for refugees in obtaining quality healthcare. Accessing appropriate and quality healthcare is critical. Among refugee populations worldwide, language and translation issues are frequently cited as barriers to quality healthcare for both physical and mental health problems. Interactions with healthcare professionals, from discussing medical history to describing characteristics and duration of symptoms, can be daunting for those with limited language skills.

Refugees face language barriers to access to health services in every country they visit (McKeary and Newbold, 2010). Although this obstacle decreases spontaneously over time, considering the importance of health service, it is inevitable to produce a solution to the language barrier. The use of interpretation services to eliminate this obstacle in reaching their healthcare Syrian refugees in Turkey has been seen as a solution. However, the size of the refugee population and this population to be distributed to the different regions of Turkey, and also the lack of a sufficient number of Arabic translators is a significant challenge. This situation has forced the Ministry of Health and the WHO Regional Office of Gaziantep to find a new solution for refugees' health. In this context, with the project developed, it is aimed that bilingual people (Arabic and Turkish), who have received high school or university education, can undergo a structured short-term education and help the patients and healthcare workers to communicate. The project was planned in 2016 with the aim of raising 960 bilingual medical interpreters and patient guides and then employing them in the migrant health centres and health facilities.

The project "To provide and coordinate lecturers for the delivery of curricula developed by Ankara University and evaluation of the Adaptation Component for Refugee Health Trainings for Syrian Translators/Patient Guides", which was implemented between the years of 2016 and 2018, consists of three stages, including the preparation of educational materials, training and employment. The training phase of this project, which is the subject of this research, was carried out by faculty members of the Ankara University Faculty of Health Sciences. Training materials were developed by analysing the training needs of the participants. The same teaching staffs participated in 23 pieces of training with 1069 people. The training was carried out in six provinces which in Syrians' refugee live density such as Ankara, Izmir, Istanbul, Adana, Şanlıurfa and Gaziantep.

The people who will participate in the training have been determined by the exam made by the Department of Migration Health, the Ministry of Health and Yıldırım Beyazıt University, Department of Arabic Translation and Interpreting. The exam consists of open-ended questions to determine the level of speaking, writing and understanding in Arabic and Turkish languages. Although 960 people will be employed within the scope of the project, 1069 people have been invited to training due to the possibility that some participants may not be employed after the training.

Each of the training is five days and 35 hours and each participant was subjected to a test before and after the training. The training programme of bilingual interpreters and patient guide contains 4 modules. These are the Turkish health system, medical terminology, communication, and patient rights modules. Turkish health system module is a total of 7 hours training consisting of issues such as Turkey's healthcare organization structure, immigrant healthcare and health services. The medical terminology module is a practical training module that provides information about the basic structures of medical terms (prefix, suffix and roots) and medical terms about pathology, surgery, symptoms, and treatment. This module aims to provide the knowledge and skills that will help the patients and the healthcare workers in a short time and without mistake translating. This module consists of 10 hours of theory and 4 hours of practical training. The communication Module consists of 7 hours of interactive training. With this module, it is aimed to carry out activities that will improve the communication quality of patient guides with patients and healthcare workers. The patient rights module is a 7-hour training that includes information on patient rights and the ethical issues that may be encountered in healthcare. Each module was prepared by field experts in accordance with the learning objectives and the training was carried out by the same field experts. According to the results of before and after training examinations, participants who have at least 70% success are given a certificate of attendance. The aim of this study was to evaluate the effectiveness of the training given to the bilingual medical interpreter and patient guide.

Method

The aim of the study is to evaluate the effectiveness of the training program. A repeated measures design was used to test the program's effects before and after training examination results, participants’ perception of the training and training organization. In this context, participants completed a 50-question before and after training exam designed to evaluate the effectiveness of the training (Table 1). The perception of participants on the training and training organization questionnaire contains 12 statements on a 5-point scale (1=very inadequate, 2= inadequate, 3=neutral, 4=adequate, 5=very adequate). In addition to it was collected qualitative data from participants to be informed about their feelings about training and training organisation. In order to it was prepared an interview form which semi-structured and contains 12 questions that open-ended.

Table 1. According to the training modules, the number of pre-education and post-education exam questions and total score.

The quantitative data were statistically analysed using SPSS version 25.0. Data are described using mean and standard deviation or frequency and percentages. We used independent sample t-test and paired sample test analysis to explain differences before and after training exam results. The qualitative data were analysed by content analysis method. Between 2017-2019, a total of 23 pieces of training were completed and 1069 people were trained. Four people who did not participate in the before or after training exam were not included in the study.

The participants’ rights were the first priority. Therefore, the participants were given written information about research. The anonymity of the participants was ensured by not collecting any personal identifiers.

Findings

Participants in the training, 23.7% (n= 252) were women and 76.3% (n= 813) were men. According to t-test results, there is no statistically significant difference between the pre-education and post-education exam scores of two genders (Table 2). However, the difference between the exams’ score of all participants was statistically significant (t=-76,61; df=1064; p=0,000) (Table 3). This result shows that the bilingual interpreters and patient guides training has been successful.

Table 2. The t-test results of the difference between the means of pre-education and post-education exams score of gender

^*P≤0,005

Participants' opinions on education were asked with six questions. At the end of the evaluation, the mean score of the participants related to education (4.48) was quite high. According to the statements, it can be said that the participants found the training adequate and satisfying. The highest average score of the participants (4.61) was expressed in the statement about the adequacy of the educators (Table 4). This result is also supported by the analysis of the qualitative data that the participants have responded with their own expressions.

Table 3. The findings of the paired sample test of the difference between pre-education and post-education exams score

^*P≤0,005

According to this, the common views of the participants were that the instructors were experts in their fields. The views of the participants can be summarized as follows. “The instructors were all experts in their fields. I learned a lot in a very short time. Topics were told in a nice and simple way. " P1.

Table 4. Means of evaluation of the training programme

When we look at the views of the participants on the duration of their education, it has seen that 50.7% (n = 540) stated that the education period was sufficient (Table 5).

Table 5. The participants' views on the duration of the education

When the views of the participants on the organization of education are examined, it is determined that the highest score is related to transportation (4,49) and organization of courses (4,48). The lowest score was found to be related to accommodation (room, service, meals, location of the hotel etc.) (4,31). The overall satisfaction rate about the organization was found to be quite high (4.41) (Table 6).

Table 6. The perception of participants on the organization of education

Participants' responses to open-ended questions support quantitative results. The vast majority of participants thought that education has reached its goal. In addition to this, they told that the subjects they did not know before in education, even that they even learned the subjects they thought would be hard to learn like medical terms and they could use this information in medical interpreting and guidance services. However, some participants complained about the shortness of the training period. In order to reinforce the information given, they indicated that the training period should be longer or should be repeated at regular intervals. Participants are highly satisfied with the content of the training, the trainers and the organization. Besides positive opinions about education, they have criticism and suggestions. They have often been related to educational materials and accommodation. Some of the interviewees said that the use of video content in the lessons could be more effective, the lesson hours could be shorter and social organizations could be added.

Discussion and Conclusion

The health of refugees is a big problem all over the world. The fact that immigrants cannot speak the language of the host country is the biggest obstacle in accessing health services. As a solution for eliminating this barrier, the use of people who speak both languages could be as a useful option. However, in this context, it is not enough for the medical interpreter to speak and write only these languages. The interpreter's ability to provide accurate translation and guidance in the time of the patient's access to quality health service depends on own skills and knowledge such as communication, medical terms, healthcare organisation and medical ethics. In short, medical translation requires quite different knowledge and understanding than other translation services. First of all, this person, who will help the patient and the patient's relatives, should know the host country's health system, health organization and bureaucratic structure. The fact that immigrants cannot speak the language of the host country is the biggest obstacle in accessing health services. As a solution for eliminating this barrier, the use of people who speak both languages is used as an option.

However, the translator does not simply transfer the patient's problems to the healthcare workers when translating. At the same time, healthcare workers also inform the patient and his relatives. This information often contains medical terms. Therefore, the interpreter should be familiar with the widely used Greek and Latin medical terms.

The medical interpreter should be familiar with two different cultures, know the rules of verbal, written and non-verbal communication and be able to use them in communication. Another important issue that differentiates health services from other services is patient rights. In this context, the medical interpreter should be able to demonstrate the sensitivities of knowing the basic principles of medical ethics and legal situations such as autonomy and privacy of the patient.

To provide all of this knowledge and skills, as seen in Turkey example, has benefited from a short-term medical interpreter and patient guidance training program. In this context, 1069 people have been trained between 2016-2018 with the training program prepared in accordance with the training needs. In this study, in which we evaluated the effectiveness of the training program, it was observed that the results of both the male and female participants were significantly different before and after the training. On the other hand, it was observed that the participants achieved the aim of education with their statements, they were equipped with the information they could use in medical translation and guidance activities and they have found that the education and training organization is satisfactory in general.

As a result, bilingual medical interpreter and patient guides can be trained as a solution to improve migrant health in a short time with such training. However, repeating training at regular intervals and including audio-visual items in the materials used should be seen as another factor that increases the effectiveness of education. It is thought that these research results will contribute to the development of similar trainings.

References