Underlying these issues of language and communication are more fundamental concerns related to health care providers’ knowledge of the distinct linguistic, ethnic and cultural profiles of the patient
groups they serve. While this could be remedied in part by increased ethnic monitoring, there is also a need to consider the cultural competence of health service providers (Traveller Movement, 2014;
McFadden et al., 2018). This reflects the concept of ‘cultural competence’, which refers to professional attention to the ways in which cultural beliefs may influence patients’ health-related communication and behaviour (Garran & Rozas, 2013; Pinderhughes, 1989). Applied effectively, cultural competence frameworks should reflect diversity in cultural groups and aid practitioners in taking into account all aspects of a patient’s identity in assessing a patient’s health situation, equipping them to shape their practice around the practical circumstances of patients’ lives (Garran & Rozas, 2013). Services can also enhance their overall cultural competence by employing staff from immigrant or ethnic minority backgrounds (Kluge et al., 2012).
McFadden et al. (2018) highlight how Roma may find it particularly difficult to communicate with health professionals of a different gender, especially when discussing issues such as sexual and reproductive health, while also suggesting that the ‘stigma and shame’ associated with disclosure of health issues may have connections to a sense of ‘devalued identity’ arising from discrimination (p. 78). A study of Roma in Spain also elaborated on the gendered dynamics of communication between Roma patients and health professionals, with some professionals appearing to assume that Roma women would be unwilling to discuss gynaecological topics due to ‘the cultural value of virginity’ (Aiello, Flecha &
Serradell, 2018, p. 386). This study also emphasised, more generally, how health professionals neglected to explain medical information to Roma patients under the assumption that Roma either would not be interested or would not understand (Aiello, Flecha & Serradell, 2018). Professionals’ assumptions about Roma patients reflect Janevic et al.’s (2011) categorisation of personally mediated racism, in which Roma feel that they were treated differently on the basis of their ethnic identity. While Aiello et al.
(2018) recognised that this differential treatment could have it roots in socioeconomic different between Roma patients and health professionals (controlling for this possibility by recruiting Roma participants of mid-socioeconomic status), their participants still highlighted a sense of disrespect from professionals stemming from outward expressions of Roma identity. These issues point to a need for additional diversity and cultural competence training amongst health service staff, which, even if not directly related to Roma culture, can raise awareness of effective methods of meeting the needs of patient from ethnic and cultural background different from those of service providers (McFadden et al., 2018; Kluge et al., 2012).
Closely linked to the concept of cultural competence – and of great relevance to Roma migrant communities in the UK – are issues of language barriers, which have been shown to increase the potential for miscommunication between patient and provider, reduce patients’ satisfaction with services and increase the likelihood of emergency room visits (Kluge et al., 2012; Memon et al., 2016). In a study focusing on access to interpreting services for BME communities (specifically Indian, Pakistani, Bangladeshi and Chinese), Gill et al., (2009) analysed data from the Health Survey for England to find that approximately 300,000 individuals across the focal ethnic groups spoke no functional English, yet health services did not routinely document English language ability in ethnic monitoring (Aspinall, 2007).
For Roma, the near-total lack of ethnic monitoring (Traveller Movement, 2014) could complicate this issue further. When an interpreter is not present in a consultation, language discord has been shown to undermines patients’ confidence in quality of care and reduces the quality of health promotion information conveyed to the patient (Ngo-Metzger et al., 2007). Aspinall (2007) notes that monitoring patients’ language support needs has not traditionally been a priority, though the lack of data on immigrant populations’ health service use represents a trend across Europe (Kluge et al., 2012).
While NHS England’s principles for interpreting and translation services recommend provision of interpreting services at the point of delivery, this does not constitute a guarantee that professional interpreters will be provided across NHS services (NHS England, 2015a). Notably, the NHS’s Accessible Information Standard does not make provision for interpreting services, claiming that requiring health service providers to account for patients’ differing language needs would place disproportionate burden on services operating in areas with large immigrant populations (NHS England, 2015a). Provision of high quality language support is patchy across the UK, and even when interpreters are available, this does not guarantee culturally sensitive delivery of health information (El Ansari et al., 2009). In this vein, bilingual health advocacy programmes – which provide not only literal translation, but also give patients a ‘voice’ – have been cited as models of good practice, yet there are no established methods for commissioning, monitoring or recruiting for these services (El Ansari, 2009).
Despite statutory recognition of the potential for heightened risk of interpreting errors when family members without formal training serve as interpreters (NHS England, 2015b), patients may see no option but to bring English-speaking family members to appointments when services do not provide formal interpreting support. In these cases, the close personal relationship between the patient and the interpreter decrease the likelihood that patients will disclose sensitive health information, thus
inhibiting providers’ ability to make diagnoses and recommendations (Hadziabdic et al., 2014). Lack of prior personal contact with an interpreter can help to mitigate feelings of shame in disclosing health conditions, and can moreover eliminate the fear that the interpreter will spread personal details about a patient to other members of the patient’s community (Hadziabdic et al., 2009). Even in the absence of language barriers, limited constructive dialogue between provider and patient can increase the likelihood that the patient will view the provider’s communication methods as ‘patronising’ and lead to low expectations of care (Van Cleemput et al., 2007; Gill, 2009; Parry et al., 2004; Greenfields, 2017).