Effective Communication for People with Refugee Experience
- 1 Introduction
- 2 Key Considerations
- 2.1 At the Beginning of an Interaction
- 2.2 During an Interaction
- 3 Resources
- 4 References
Effective and respectful communication is central to all refugee work. Communication is the process of exchanging information, ideas and thoughts between two or more individuals, which can include verbal and non-verbal forms. Effective communication is important as it can provide the basis for building good interpersonal relationship. In the healthcare setting, effective communication through the use a range of different communication skills and techniques, can create a more effective therapeutic setting leading to improved outcomes and attainment of goals.  The ability to communicate is a key to providing physiotherapy services. A treatment session is a joint project between the therapist and the client, and it is essential to have something in common to do something together. Establishing common ground is therefore essential. Rehabilitation services in physiotherapy is typically stretched over time, which gives a unique opportunity to do this. Although communication can be one-directional, like listening to the radio, or the physiotherapist telling the patient what “to do”, we understand communication as an active process where messages are exchanged between two or more individuals. The concept “effective communication” used by some, covers the ability to listen as well as interacting with clients based on a mutual understanding, which is the essence in culturally sensitive care. Communication in rehabilitation is an ongoing process between the physiotherapist and clients who have refugee experiences.
A refugee is someone who has been forced to flee their country and crossed an international border to find safety in another country as a result of persecution, war or violence. Establishing communication is often a challenge, as they may be speaking a different language or a different dialect. Communication and the difficulties that arise due to language barriers is a prominent and recurring theme in the literature. Language barriers can lead to negative health outcomes, decreased adherence to treatment plans or a patient’s unwillingness to participate in rehabilitation treatment. A recent study by the BBC Media Action  examined the needs of refugees in relation to communication and access to information, as well as the challenges humanitarian agencies face when it comes to providing for the needs of refugees. The study highlights that communication should not only about providing information, but that refugees need to be listened to, to be able to tell their stories, to participate in dialogue that provides them with physical, social and psychosocial support and, trauma counselling. Physiotherapists and allied health care providers need strong, culturally competent communication skills to ensure that appropriate care is provided to their patients. Communication efforts should also take into account the diversity. Diverse, multiple, formal, and informal methods of communication can help overcome barriers to effective communication with refugees. You can read more about Culture and Communication here.
At the Beginning of an Interaction
Trust is a key factor when it comes to communicating with refugees and can be both a catalyst or a barrier in establishing communication. Trust is defined by the Merriam-Webster Dictionary as “assured reliance on the character, ability, strength, or truth of someone or something”.  Having trust in healthcare workers involves reliance on the capabilities and competence of the staff, even with the existence of uncertainties and without assurance. At the beginning of all interactions, it is key that physiotherapists and health and social care professionals try to make the individual or group feel comfortable in order to build this trust and create an environment where they feel safe to communicate and share information.
Creating Therapeutic Space and Alliance
Creating a therapeutic space involving refugees may involve some challenges as a result of communication barriers, cultural differences and other factors. However, these challenges can be overcome within the healthcare setting through use of a wide range of strategies; including use of interpretation and translation services, cultural mediation with appropriate adaptation of health information and materials and guidance and training for health staff. 
First create an environment that fosters trust, safety and respect and encourages participation of the patient in creating goals, which has been shown to lead to better outcomes. Adjust the physical space to create a positive environment, ensuring privacy. The encounter between the physiotherapist and refugee or migrant typically starts in a therapy room. Although the therapeutic room varies based on circumstances, the situation and setting becomes a sociocultural space and per se, it is the physiotherapist’s home ground. The environment has the potential to could create disparity, as the professional is “at home” while the care seeker is “visiting". Further, the physiotherapist represents authority, and challenging authority might be uncommon and scary for the patient. It is important to be aware that tacit and unwritten rules such as these, and others represent barriers for culturally sensitive communication and could influence the rehabilitation process. These barriers need to be overcome to balance the relationship between the therapist and patient. Simple strategies such as removal of physical barriers between you and the refugee, such as desks or computers, may be beneficial in order to demonstrate that you are equal. 
Secondly actively create a relaxed atmosphere to foster a relationship of trust and respect. Something as simple as greeting them in their language can provide a positive start to the interaction, while still maintaining a high level of professionalism.
- Clarify your role when you first contact the client.
- Introduce any other participants, such as interpreters at the beginning and explain why they are present.
- Ensure the patient knows that they are free to take a break at any point, if they need it.
- Be realistic and specific when discussing what help you can offer.
- Focus on establishing rapport. It may take a number of sessions to identify the real issue.
- Don’t assume you understand the client’s problem - clarify it with them.
Consent and confidentiality are vital aspects to consider when working with vulnerable populations, including refugees. Vulnerability refers to the fact that their disorder or life circumstances has disadvantaged them against others. Some refugee clients are unfamiliar with the concept of confidentiality, and reluctant to trust interpreters and service providers, particularly those from their own community.Due to the sensitive and private nature of many interactions, both formal and informal, refugees might be reluctant to talk about complex issues that may impact on their health. Take precautions to ensure and maintain the confidentiality of information for everyone involved. Clearly stating who will or will not have access to the information can help create a safe environment in which the person feels able to communicate openly. Where confidential information needs to be shared with others, discuss this with the individual and ask for consent.
Use of Interpreters and Translators
Sometimes an interpreter is required in the therapy room. The presence of a third person, could influence communication in many ways. Interpreters do not replace the interviewer, but play a vital role in facilitating communication with a refugee. Their presence can help or harm communication. An Interpreter is a skilled and trained person that converts oral information into another language, while a translator is a skilled and trained person that converts written information into another language.  Their role is to make clear communication between the health care provider and the refugee who are both speaking different languages. Their goal is to convert oral or written information as “meaning for meaning” and not as “word for word”. This implies that interpretation and translation must be done with some context of the message being conveyed as well as the emotions and expressions it was delivered with. 
Key Points for Communicating with Interpreters
- Whenever possible, use certified interpreters and ensure they have adequate language and interpreting skills and the necessary training.
- Consider the age, gender and diversity characteristics of the interpreter that may make the refugee more open to communicating (e.g. selecting a female interpreter when speaking with a female refugee).
- Address and make eye contact directly with the refugee, not with the interpreter. Avoid talking to the refugee “through” the interpreter.
- Shorten the sequence of your sentences. Select your words carefully in order for the interpreter to clearly understand. Adjust the kind of language that you normally use e.g. less medical or formal words and avoid use of acronyms.
- Ensure that the information and correct meaning is not lost in translation. To avoid misinterpretation and loss of information, if you have sufficient time, apply triangulation techniques (i.e. rephrasing responses, reformatting questions) in order to minimise loss of information from interpretation.
- Interpreters should not have to feel the need to filter what they are translating. No matter how crude, harsh, or offensive, the interpreters should still translate exactly what was said from the patient. The purpose of this is to enable medical professionals to gain a full understanding of how the patient is feeling. It is the medical professional’s job to work out what is going on if the conversation is going off topic. The health care professional should encourage the interpreter to translate EXACTLY what the patient has said at all times. Remain alert to any signs of potential problems with the quality of the interpretation (for instance if the response does not answer your question; the interpretation is significantly longer or shorter than appears appropriate; words you recognize without interpretation are not interpreted; exchanges between the interpreter and the refugee are not interpreted)
- It is CRUCIAL to ensure that the interpreters you work with have breaks and adequate rests. Breaks are VERY important for interpreters and mental fatigue can massively affect the quality of translation. Also consider the potential psychological effects of either past experiences or interpreting the trauma of patients, it is so important to make sure that they do not burn out 
Be aware that a refugee may also feel more reluctant to participate in meaningful communication if the interpreter present is not trusted. You can read further details about the Use of an Interpreter and Translator for People with Refugee Experience.
During an Interaction
Pay Attention to Cultural Considerations
Culture, education, and experience influence the physiotherapist’s communication style and skills and the same can be said for the patients. Communication can take on different forms, it can be verbal or non-verbal, it can be expressed by facial expressions and body language, and even silence. The dialogue is central: using language in some form to exchange ideas and thoughts. A dialogue implies that the involved parties listen aiming at creating something together that is meaningful in the situation. It also implies an ability to take on the other person’s perspective. By asking questions, listen to the answers and acknowledge the stories told, it is possible to establish a therapeutic alliance built on trust. This is particularly important in the treatment of vulnerable groups, such as refugees and migrants. It could also create new knowledge and insights for all involved parties.
Communication is central and important in all types of clinical work. Communicating is something we do every day. We are used to it; it is simple but still complicated as many barriers and factors come into play and disrupt communication. Physiotherapists working with refugees need to utilise a client centred approach in rehabilitation service. This implies offering culturally sensitive care, which includes the ability to communicate appropriately with the person seeking help. For many refugees and migrants their cultural background is often very different from that of the country where they seek physiotherapy and rehabilitation services, which can be a challenge. Consider refugees culture as well as your own and be aware of other factors, such as health conditions, distress and emotions that may influence your conversation. We also need to be aware that our own culture may give us certain biases, which we need to be able to acknowledge and recognise the influence these may have on our way of communicating. 
Health care professionals do not have to be cultural experts, but do need to try to understand their client and to communicate effectively with them. The following will help you negotiate many cultural differences:
- Ask the client what their expectations are and how things were done in their country
- Acknowledge and respect differences that may exist between your beliefs, values, and ways of thinking and that of your client. Talking about the differences may help give your client a framework for understanding your culture.
- Make an effort: even showing a basic knowledge and an interest in their culture can be invaluable to clients trying to adjust to their new healthcare system
- Avoid generalisations about cultural groups: there is variety within each culture that’s influenced by urban or rural background, education, ethnicity, age, gender, social group, family and personality
In the clinic, it is the patient’s needs that guides the communication. Still, most likely it is the physiotherapist who controls the communication by initiating the dialogue and by selecting the follow-up questions and topics. However, the therapist must facilitate the dialogue so that the client has an opportunity to present their story. It is also the therapist’s obligation to make clear that they have heard what has been said, and to use the story as a starting point for further communication.
Communication can only be effective if everybody involved is attentive to what each other is saying. Instead of focusing only on conveying your messages, pay close attention to what the refugee is saying. Active Listening, also known as reflective or empathetic listening, is useful in this situation. It has been shown to improve interpretation of the sender's message, which, when dealing with patients, is a critical skill. Poor listening has been attributed to inaccurate diagnosis and incorrect treatment. Asking questions and responding effectively as part of this process ensure the refugee is at the centre of the interaction and that they feel heard, valued, understood and respected.Guidelines for active listening include;
- Physically adjust your body to encourage two-way communication.
- Listen carefully without judgement, by giving your full attention and avoid interrupting.
- Pay attention and .inimise distractions. Avoid looking at your phone, computer or anything else that could distract you from the interaction.
- Show interest and create a positive atmosphere
- Use reflections
- Don't get emotionally involved
- Use non-verbals to show you are listening, such as nodding or say "I see."
- Invite further disclosure with phrases such as "tell me more."
- Clarify with open-ended questions, particularly when seeking a description or an elaboration on an answer
- Paraphrase what they have said to demonstrate that you have listened, understood correctly and to show that it is important to you.
- Use non-judgmental phrasing in your responses and follow-up questions.
Consider Non-Verbal Communication
Non-verbal behaviour or body language such as gestures, facial expressions, movements and tone of voice can convey receptivity, interest, comprehension, hostility, disinterest, anxiety or discomfort. Interestingly, in cases where verbal and non-verbal messages contradict each other, non-verbal communication tends to outweigh the verbal message. Empathy and emotion are communicated more distinctively via non-verbal communication than verbally, making good non-verbal communication an integral, often overlooked part of the medical interview. Empathy is expressed by acting warm, friendly and reassuring, and has been linked with better patient satisfaction and recovery rates, and subsequently better health outcomes. Take an inventory of your body language and consider what the expressions or gestures of the person you are communicating with suggest. Do they fit the accompanying words or does the person’s body language convey a different message? 
Talking to Persons who are Distressed
Persons who have experienced potentially traumatic events may be unable to speak of them or may be triggered easily by certain topics of communication. While a refugee may present with common problems such as grief, trauma symptoms, depression, anxiety, emotional stress or suicidality, the underlying problem may be their experiences of torture and/or trauma. There are different levels of distress, but some easily recognisable physical reactions include: tiredness, nervousness, and avoidance of eye contact. Clients with PTSD may fall silent, lapsing into a dissociative state to avoid the memory.
Talking about certain events can potentially renew wounds or fears so be aware that even well-intentioned questioning may feel like an interrogation to refugees. Some topics like rape, abuse, harassment, and torture are sensitive and difficult to bring forward. Communication around these topics requires a sound therapeutic alliance based on trust and mutual recognition.Those with strong numbing symptoms may present as withdrawn, unresponsive and difficult to engage with. It’s impossible to anticipate all the circumstances that could retraumatise your client, but you can minimise the risk by avoiding settings or behaviour that could remind them of interrogation or torture experiences.
Provide Space for Managing Anger or FrustrationExperience of conflict, human rights abuses and displacement may increase feelings of insecurity, fear, anger or frustration, reducing people’s ability to clearly state how they feel or to express their point. It is important to create an environment in which refugees can fully express their anger, or frustration, particularly where it impacts on their health and well being. Be understanding: many refugees have survived traumatic events and struggle with daily challenges, and may have had to wait a significant period of time before accessing health care support. Remember that acceptance of the other’s emotions creates trust and that the anger is likely aimed at the situation and not directly at you.
Migrants in Countries in Crisis (MICIC)
- Guideline 6: Communicate Effectively with Migrants. This guideline from Migrants in Countries in Crisis (MICIC) on communicating effectively with migrants, presents efforts by different stakeholders to adapt and effectively share awareness messages and early warnings with migrants. It also presents a tool for conducting awareness workshops on emergencies and recommended preparedness measures for migrant representatives.
Migrant and Refugee Women’s Health Partnership
- Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds - Competency Standards Framework for Clinicians January 2019. The Framework was developed by the Partnership, a national initiative bringing together health professionals—through their respective peak professional and standard setting bodies—community sector representatives and government to address systemic barriers to health access and outcomes when delivering care to people from migrant and refugee backgrounds, while acknowledging and responding to the unique challenges faced by women within this cohort.
- Increasing two-way communication with refugees on the move in Europe. This report highlights and showcases some of the innovative approaches that have been taken to address complex refugee communication challenges and discover new opportunities.
- Effective and Respectful Communication in Forced Displacement. This resource provides detailed guidance on dealing with and managing stress and emotions, enabling individuals to treat persons of concern with dignity and empathy, and to further facilitate and strengthen effective communication.
- What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region? This scoping review examines strategies which have been implemented and evaluated to address communication barriers experienced by refugees and migrants in health care settings across the WHO European Region. Four main types of strategy were identified: cultural mediation, interpretation, translation of health information, and guidance and training for health care providers. These have been used to support access to health care, management of specific diseases and promotion of health across a wide variety of health care settings.
- Roohangiz Norouzinia. Maryam Aghabarari. Maryam Shiri. Mehrdad Karimi. Elham Samami.Communication Barriers Perceived by Nurses and Patients. Global Journal of Health Science [Internet]. 2015 Sep [cited 2020 Jun 16]. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954910/doi: 10.5539/gjhs.v8n6p65
- Theodora Hannides. Nicola Bailey. Dwan Kaoukji. Voices of Refugees Information and Communication Needs of Refugees in Greece and Germany. Research Report. BBC Action Media. [Internet] 2016 Jul [cited 2020 Jul 26]. Available at https://reliefweb.int/sites/reliefweb.int/files/resources/voices-of-refugees-research-report.pdf
- Merriam-Webster Dictionary [cited 2020 Jun 23]
- Division of International Protection, United Nations High Commissioner for Refugees. Effective and Respectful Communication in Forced Displacement
- McGarry O, Hannigan A, De Almeida MM, et al. What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region? Themed Issues on Migration and Health, IX. 2020. Available at https://www.ncbi.nlm.nih.gov/books/NBK534367/
- UNHCR, Self-Study Module 3: Interpreting in a Refugee Context, (1 January 2009), at: http://www.unhcr.org/refworld/docid/49b6314d2.html
- Medical Volunteers International (2019) Inservice Training by German Sign Language interpreter, Lesvos Greece.
- UNHCR Innovation. Boda Boda Talk Talk: improving information-sharing with refugees in Uganda. Available from: https://youtu.be/S8ZQW5JJo6Q[last accessed 30/11/2020]