title: Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study.
abstract: Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice.
  
  
  
  We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers' fieldwork reports, were coded and thematically analysed by each team using NPT.
  
  
  
  In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants' needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP's diagnoses and GPs reported a clearer understanding of migrants' symptoms.
  
  
  
  Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, NIjmegen, the Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Teunissen
authors.affiliation: Department of Psychological Sciences, B121 Waterhouse Buildings University of Liverpool, Liverpool, United Kingdom.
authors.forename: K
authors.initials: K
authors.lastname: Gravenhorst
authors.affiliation: Department of Psychological Sciences, B121 Waterhouse Buildings University of Liverpool, Liverpool, United Kingdom.
authors.forename: C
authors.initials: C
authors.lastname: Dowrick
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, NIjmegen, the Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Van Weel-Baumgarten
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, NIjmegen, the Netherlands.
authors.forename: F
authors.initials: F
authors.lastname: Van den Driessen Mareeuw
authors.affiliation: Discipline of General Practice, School of Medicine, National University ofIreland, Galway, Ireland.
authors.forename: T
authors.initials: T
authors.lastname: de Brún
authors.affiliation: Faculty of Health and Medicine, Lancaster University, Lancaster, UK and General Practice & Primary Care, Institute of Health & Wellbeing, College of MVLS, University of Glasgow, Glasgow, UK.
authors.forename: N
authors.initials: N
authors.lastname: Burns
authors.affiliation: Clinic of Social and Family Medicine, University of Crete Medical School, Crete, Greece.
authors.forename: C
authors.initials: C
authors.lastname: Lionis
authors.affiliation: General Practice & Primary Care, Institute of Health and Wellbeing, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
authors.forename: F S
authors.initials: FS
authors.lastname: Mair
authors.affiliation: General Practice & Primary Care, Institute of Health and Wellbeing, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
authors.forename: C
authors.initials: C
authors.lastname: O'Donnell
authors.affiliation: Discipline of General Practice, School of Medicine, National University ofIreland, Galway, Ireland.
authors.forename: M
authors.initials: M
authors.lastname: O'Reilly-de Brún
authors.affiliation: Clinic of Social and Family Medicine, University of Crete Medical School, Crete, Greece.|Department of Social Work, School of Health and Social Welfare Technological Educational Institute of Crete Heraklion, Crete, Greece.
authors.forename: M
authors.initials: M
authors.lastname: Papadakaki
authors.affiliation: Clinic of Social and Family Medicine, University of Crete Medical School, Crete, Greece.
authors.forename: A
authors.initials: A
authors.lastname: Saridaki
authors.affiliation: Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1st floor, A-1090, Vienna, Austria.
authors.forename: W
authors.initials: W
authors.lastname: Spiegel
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.|Australian Primary Health Care Research Institute, Nijmegen, the Netherlands.
authors.forename: C
authors.initials: C
authors.lastname: Van Weel
authors.affiliation: Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. Maria.vandenMuijsenbergh@radboudumc.nl.|Pharos, Centre of Expertise for Health Disparities, Utrecht, the Netherlands. Maria.vandenMuijsenbergh@radboudumc.nl.
authors.forename: M
authors.identifier: 0000-0002-4994-4008
authors.initials: M
authors.lastname: Van den Muijsenbergh
authors.affiliation: Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
authors.forename: A
authors.initials: A
authors.lastname: MacFarlane
mesh_terms: D003142:Communication; D003144:Communication Barriers; D054521:Cultural Competency / Q000193:education*; D004493:Education; D054242:Emigrants and Immigrants; D005060:Europe; D005260:Female; D017144:Focus Groups; D019983:Guideline Adherence; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D018794:Problem-Based Learning; D036301:Qualitative Research; D012017:Referral and Consultation; D014171:Transients and Migrants
keywords: Community-Based Participatory Research; Cross-cultural communication; Equity; General Practice; Primary Health Care; Transients and Migrants