What is inequality in healthcare?

Everyone in the Netherlands is obliged to have basic health insurance. Yet not everyone receives care in the same way. According to Associate Professor Barbara Schouten, inequality is about whether you can receive care in a timely, appropriate way, and in the right place.

‘In mental healthcare (GGZ), the waiting lists are long. It affects everyone. But for people who speak little or no Dutch, these waiting lists are often even longer.’

‘If there is no interpreter available for a less common language, people sometimes have to wait for months. In some cases, they even drop out of the process entirely and no longer receive any treatment.’

Lack of cultural competence

When patients with a migration background do make it into mental healthcare, a proportion of them stop treatment before finishing the process. This is due to the cultural competence of healthcare professionals, Schouten discovered in her research: ‘They are well trained in terms of theory, but hardly prepared to work with diverse patient groups.’

‘Culture determines how people think about illness, how you express pain or sadness, and what you expect from treatment,’ Schouten continues. ‘Not all concepts exist in every language. The word “depression” does not exist everywhere, or it has a different meaning. If healthcare professional and patient do not share the same concept, they understand each other less well. Then it becomes more difficult to make a diagnosis and provide the right care,’ Schouten explains.

Language barrier

In addition to culture, there is often a language barrier. If patient and healthcare professional do not share a common language, patients often bring family members or neighbours along as interpreters. Schouten sees that this often causes problems: ‘The family member may not speak Dutch well enough and may not be able to translate difficult medical terms accurately. Sometimes children also come along as interpreters, because they learn Dutch more quickly at school or from other children. But imagine a child having to tell his or her mother that she has cancer. That is emotionally far too heavy for a child.’

The presence of the interpreter can also lead to other problems. Schouten gives an example of a woman who brought her husband as an interpreter to see a therapist. Because her husband was in the room, she did not dare to talk about a rape incident of which she had been a victim.

Discrimination

Inequality in healthcare is also caused by discrimination. In a Dutch report, about half of people with a migration background indicated that they experience discrimination in healthcare. Schouten explains why:

‘They feel that they aren’t taken seriously. That ranges from being spoken to in a condescending way, heavy sighing, comments such as “they have lived here for 50 years and still do not speak Dutch”, to stereotypes such as “that Turk is complaining again”.’

These experiences damage trust in healthcare. People become less willing to share their symptoms and sometimes stop going to the doctor altogether. In this way, inequality increases.

How can we solve this?

In collaboration with healthcare organisations, Schouten not only studies the problems but also works on solutions. She develops digital tools to improve access to care: from an information platform with understandable explanations to an instrument for assessing what kind of language support is needed during an appointment.

Multilingual healthcare platform

In the European Union, roughly one in eight people has mental health problems, such as stress, worries, anxiety or grief. Refugees and people with a migration background are at even greater risk of mental health problems. This is due to stress during the migration process, uncertainty and often difficult living conditions.

Schouten led the project MentalHealth4All, a digital platform with information in fifteen languages, supported by animations. The platform covers themes such as: ‘What if you do not feel a connection with your healthcare professional?’ It offers patients explanations about symptoms and possible treatments, in understandable language.

MentalHealth4All is also aimed at healthcare professionals. The platform contains explanations and short training modules on how to deal with cultural differences between patient and doctor. It also features a map showing organisations that provide culturally sensitive healthcare. ‘These are organisations that employ people from the same communities, such as Turkish or Moroccan therapists. There are also transcultural psychiatrists: they do not come from the community themselves, but they are well trained in the problems migrants face,’ says Schouten.

Research shows that the platform works. Patients view mental healthcare more positively and experience care as more culturally sensitive.

Support for language assistance

Schouten also developed a tool for deciding what language assistance is needed during a healthcare appointment. The MediLanguage instrument helps assess how complex a conversation will be and then offers advice: is a professional interpreter needed, or is a translation app sufficient?

‘If someone is only coming in to pick up a repeat prescription, Google Translate will do just fine. For other appointments, it may be enough to have an interpreter join by phone. There are too few professional interpreters to be present at all consultations. MediLanguage helps to deploy the available interpreters in a smarter and more efficient way', says Schouten.

Training for healthcare professionals

Schouten is currently working on training for mental healthcare professionals to improve how they work with professional interpreters. The training focuses on maintaining direct contact with the patient, providing a good briefing for interpreters, and establishing a clear division of roles during the conversation.

More accessible healthcare

Full equality in healthcare does not yet exist and may not be achieved any time soon. Nevertheless, according to Schouten, steps have been taken in the right direction.

‘Increased awareness of language and cultural differences, better digital tools and smarter use of interpreters together contribute to more accessible healthcare.’

About Barbara Schouten

Barbara Schouten is an Associate Professor at the University of Amsterdam, where she studies intercultural health communication within the programme group Persuasive Communication. She leads and participates in various national and international research projects on language barriers and access to healthcare, often in collaboration with universities across Europe and practice partners such as interpreting agencies and migrant health funds. Her work is supported by funding from NWO, ZonMw, KWF and EU-AMIF, and within the UvA she is involved in the research priority area Urban Mental Health.