BMC Public Health Comparing three short questionnaires to detect psychosocial dysfunction among primary school children: a randomized method

Antonius Gc Vogels
Matty R †1
Prevention and Healthcare
TNO (Netherlands Organisation of Applied Scientific Research) Quality of Life
The NetherlandsPO Box 22152301 CELeiden

Crone
Department of Public Health and Primary Care
Leiden University Medical Center
The NetherlandsLeiden

Femke Hoekstra
Epidemiology, Documentation and Health Promotion
Municipal Health Service Amsterdam
AmsterdamThe Netherlands

Sijmen A Reijneveld
Department of Health Sciences
University Medical Center Groningen
University of Groningen
GroningenThe Netherlands

BMC Public Health Comparing three short questionnaires to detect psychosocial dysfunction among primary school children: a randomized method
10.1186/1471-2458-9-489BioMed Central Page 1 of 12 (page number not for citation purposes) Research article Email: Antonius GC Vogels* -firstname.lastname@example.com; Matty R Crone -firstname.lastname@example.com; Femke Hoekstra -firstname.lastname@example.com; Sijmen A Reijneveld -email@example.com * Corresponding author †Equal contributors
Background: Good questionnaires are essential to support the early identification of children with psychosocial dysfunction in community based settings. Our aim was to assess which of three short questionnaires was most suitable for this identification among school-aged childrenMethods:A community-based sample of 2,066 parents of children aged 7-12 years (85% of those eligible) filled out the Child Behavior Checklist (CBCL) and -randomly determined -one of three questionnaires to be compared: the Strengths and Difficulties Questionnaire with Impact Supplement (SDQ), the Pediatric Symptom Checklist (PSC) and the PSYBOBA, a Dutch-origin questionnaire. Preventive Child Healthcare professionals assessed children's psychosocial functioning during routine health examinations. We assessed the scale structure (by means of Structural Equation Modelling), validity (correlation coefficients, sensitivity and specificity) and usability (ratings by parents and professionals) of each questionnaire and the degree to which they could improve the identification based only on clinical assessment (logistic regression).Results:For the three questionnaires, Cronbach's alphas varied between 0.80 and 0.89. Sensitivities for a clinical CBCL at a cut off point with specificity = 0.90 varied between 0.78 and 0.86 for the three questionnaires. Areas under the Receiver Operating Curve, using the CBCL as criterion, varied between 0.93 and 0.96. No differences were statistically significant. All three questionnaires added information to the clinical assessment. Odds ratios (95% confidence intervals) for added information were , SDQ: 55.0 (23.1-131.2) and PSYBOBA: 68.5 (28.3-165.6). Parents preferred the SDQ and PSYBOBA. Preventive Child Health Care professionals preferred the SDQ.Conclusions: This randomized comparison of three questionnaires shows that each of the three questionnaires can improve the detection of psychosocial dysfunction among children substantially.

Background

Psychosocial problems are quite common among children. Prevalence rates vary with age, methods used and sample. Brugman et al. reported that clinicians identified such problems among 25% of 4480 school aged children invited for a routine health check-up [1]. In another study [2], family physicians identified problems in approximately 22% of 898 children aged 5 to 15 years. Kelleher and co-workers reported that paediatric and family practice clinicians identified psychosocial problems among 19% of a national sample of children aged 4-15 years [3]. Reijneveld et al found that nearly nine percent of parents reported frequent concerns, mostly about their child's behaviour [4]. Only a minority of children with such problems are treated for these problems. Verhulst found that only 13% of children with behavioural or emotional problems were referred to mental health care [5]. Reliable and valid questionnaires can improve early detection of such problems and the following treatment of these children and thereby improve these children's prognosis significantly and substantively [6].

Community paediatric services, like those in the USA and the Netherlands, offering routine health care services to the population as a whole, are in a unique position to detect children with psychosocial problems. In the Netherlands this early detection is an explicitly formulated task of the existing Preventive Child Healthcare (PCH). Dutch PCH services invite all children in their region for a regular health examination at specified moments in their development. This health examination includes both physical and mental health. When problems are detected children are referred to the family doctor or specialized care. The level of show up is high: PCH reaches about 95% of all children. Without reliable and valid questionnaires, many children with mental health problems are likely to be missed. For instance, Brugman and co-workers showed that PCH, without such instruments, identified problems among 25% of the children, but 43% of the children with a clinical score on the CBCL were missed [1]. Introducing valid instruments will also reduce the number of false positives.

The CBCL is a strongly validated instrument to assess psychosocial problems in children. Unfortunately, it does not meet the practical requirements for widespread use in Dutch PCH. Instruments to be used in PCH must be short, easy to answer and -due to the limited time available for a standard health examination -easy to score. Clearly, the CBCL with its 120 items does not meet this criterion.

Several short instruments are available for use among school-aged children that do meet these practical requirements: the Pediatric Symptom Checklist (PSC) [7][8][9][10], the Strengths and Difficulties Questionnaire (SDQ) [11,12], and a newly developed Dutch instrument, the PSYBOBA (a Dutch acronym, standing for 'Questionnaire for psychosocial problems among primary school children aged 7 to 12) [13]. These questionnaires aim to detect behavioural and emotional problems in children in primary education and are available in parent form.

The aim of this study was to compare the psychometric properties of these questionnaires in a randomized diagnostic method to select the best questionnaire for routine use in community based PCH for primary school children. More specifically: which questionnaire enables PCH to distinguish best between children with and without problems, offers PCH most information not already available from other sources and is most suitable for use in routine practice, for parents and for PCH professionals?

Methods

We developed a randomized procedure in which we compared the questionnaires on a number of predefined criteria, using data that we collected in an identical way for each of the questionnaires to be assessed. To guarantee complete equivalence of data, we used a community sample of parents who all filled out the Child Behavior Checklist (CBCL), but were randomized to fill out one of the three questionnaires to be evaluated (PSC, SDQ or PSY-BOBA). Next, we obtained information from the PCH professionals, blinded for the parental questionnaire, about background characteristics and psychosocial problems detected by PCH professionals.

Sample

We obtained our sample in two steps. First, we divided the country in four regions, excluding the three largest Dutch cities, as we knew they could not participate. PCH services were then asked if they could participate in the study. Out of the respondents, we selected nine regional PCH services, stratified by region, that covered both urbanized and non urbanized areas. Second, these PCH services asked parents, invited for a routine well-child visit, to participate. Out of 2426 eligible parents, 2066 were willing to participate (85%); 25 of them provided incomplete data, resulting in a final response of 84%.

PCH professionals were able to provide some information on the non-responders (e.g. age, gender, ethnicity, family composition and past treatment because of psychosocial problems). Responders and non-responders did not differ by age and gender, but children from ethnic minorities were overrepresented among the non-responders (16% vs. 6% among the responders). Table 1 presents background characteristics of the sample and non-responders.

Randomization

Parents received either of the three questionnaires in a random way: the researchers put the CBCL and one of the three other questionnaires in closed envelopes. PCH employees sent these to the parents without knowing which envelopes contained which questionnaires. We found no differences in background characteristics of the sub-samples that received either of the three questionnaires.

Determination of Sample Size

We aimed at a sample size of 700 respondents for each of the questionnaires to be evaluated. Earlier studies [1,14] had shown that short questionnaires used in paediatric settings allow for an Area Under the Receiver Operating Curve index (AUC) of about 0.90 with a clinical CBCL Total Problems Score (TPS) as criterion. Sub-sample sizes of 700 are sufficient to detect, with α = 0.05 and a power of 0.80, a difference between AUCs of 10 points around 0.90. PCH services continued data collection until the required number of questionnaires was reached.

Procedure and Measures

The data were collected during routine preventive health assessments of children aged 7-12, between September 2003 and July 2004. Data collection procedures closely resembled those in other studies [14][15][16] and were known to result in high response rates. The CBCL and either the SDQ or the PSC or the PSYBOBA were mailed by the PCH services to the parents along with the standard invitation for the well-child assessment, in a closed envelope. Parents filled out the questionnaires, and gave them back to the PCH services in another closed envelope. The services passed them to the researchers, without opening the envelopes.

PCH professionals then interviewed parent and child and examined the child. After each assessment the PCH professionals answered the question: "Does the child have a psychosocial problem?" (yes, no). PCH was explicitly instructed to distinguish between children having psychosocial problems and children that only have risk indicators for such problems. Children for whom only risk indicators but no emotional or behavioural problems were detected, had to be coded as having no psychosocial problems. The phrase 'psychosocial problems' was defined as referring to internalizing and externalizing problems, whether serious or not

The Dutch version of the CBCL was used to assess behavioural and emotional problems. The CBCL has a substantive concurrent and predictive validity, also in the Dutch version [5,[17][18][19]. It allows for the calculation of a total problems score (TPS) and several syndrome and broadband scores. Children were allocated to a normal, borderline or clinical range, using the cut-off points recommended in the Dutch manual [18]. These depend on age an gender and are based on the 82 th and 90 th percentiles of the raw scores in the Dutch normative sample, for a borderline and clinical score, respectively.

The SDQ Parent Form is a 33 item behavioural screening questionnaire [11,12,20,21]. It was developed in Great Britain, but is now available in more than 50 languages.

Several studies indicate good psychometric properties, in different settings and in different nationalities [22][23][24][25][26][27][28][29].

The SDQ with the Impact supplement consists of 25 items relating to the child's strengths and difficulties and eight items relating to the impact of problems. These last items are not included in the calculation of the total problem scale and were not included in the analysis. The other 25 items allow for the calculation of five subscales (Emotions, Behaviour, Peers, Hyperactivity, Prosocial Behaviour) and a total problem scale (summing the first four sub-scales). We used the parent form of the Dutch version, available at http://WWW.SDQINFO.COM.

The PSC is a 35 item questionnaire for parents, assessing psychosocial dysfunction of their children. It was developed in the USA. Several studies have shown its good psy-chometric properties [9,[30][31][32][33]. A single total problem score is calculated. No official Dutch version of the PSC was available. Therefore, this questionnaire was translated following a procedure advised by Guillemin, using three independent translators and back-translators and the advice of the original authors [34].

The PSYBOBA is a recently developed Dutch instrument for parents, designed specifically for Dutch PCH [13]. It contains 26 items, on the child's behaviour and emotions. These items allow for the calculation of a single problem scale. Four additional items, on stressful life events and parental worries, are not included in the problem scale. We added three questions to each of the three questionnaires, asking how parents rated length and difficulty and whether they had any remarks on the questionnaires.

Additionally, to get insight in the usability of the questionnaires, nine PCH professionals were asked to use each of the questionnaires in about 25 standard assessments. They rated the usability of the questionnaires, after ten assessments each, in a short rating list. This questionnaire contained ten items on how parents had answered the questionnaires, whether calculation of the scores was considered complicated and so on. Having used each of the three questionnaires PCH professionals answered another questionnaire, in which they rated each questionnaires on a scale from 0 till 10 and indicated which questionnaire they preferred.

The study was approved by the local Medical Ethical Committee, the Commissie Medische Ehiek van het Leiden University Medical Center.

Analyses

We compared the questionnaires on a number of criteria, developed in studies published before [14,15]. The main criterion variable was a clinical TPS.

First, we assessed the scale structure of the questionnaires. Cronbach's alpha was calculated. We determined the fit between the scale structure and the observed data using Amos 5 Structural Equation Modelling (SEM) [35,36]. We used Structural Equation Modelling (SEM) to assess whether our data fitted the structure of the items in the questionnaires as proposed by their developers. SEM allows to do this by means of a confirmatory factor analysis that answers this question whereas conventional factor analytic methods only allow to do an exploratory factor analysis (i.e. to find the best summary of the information of the various items, without taking into account the structure proposed by the developers). The models tested were considered as fitting when the Parsimony Adjusted Fit Index (PGFI) was higher than 0.90. The mod-els were considered as approximating fitting when the Root Mean Square Error of Approximation (RMSEA) was less than 0.08 [36] Items with regression weights ≤ 0.33 were considered as not fitting.

Next, we assessed the validity of the questionnaires, using the TPS as criterion. To assess the construct validity, we calculated the product moment correlation coefficients between the CBCL TPS and the total problem scores on the three short questionnaires. Validity in this context, however, refers primarily to the extent to which the questionnaires can distinguish between children with and without problems. Therefore, also kappa-coefficients were calculated. We calculated the AUCs and tested differences between them by means of bootstrapping. Bootstrapping is a method to estimate the potential chance variation of model parameters on the basis of the empirical distribution of those parameters instead of assumptions on the statistical distribution that these parameters should follow (such as a normal distribution). We drew 1000 samples (with replacements) for each of the three sub-samples of the same sizes as these sub-samples, compared the AUCs for each combination in these samples and calculated the probability that the AUC was smaller or greater. Furthermore, sensitivity and specificity of the three questionnaires were calculated.

The identification of children with problems is of course most relevant for those children who are not yet being treated for such children. We therefore did these analyses not only for the sample as a whole, but also specifically for children who were not treated for any psychosocial problem during the past year (information provided by the PCH professionals).

Originally, we intended to use cut-off points as found in the literature [13,37,38]. However, these cut-off points for the three questionnaires that were compared resulted in considerable differences in the prevalence rates of elevated scores (10% for the SDQ, 5% for the PSC and 32% for the PSYBOBA), while the percentages of children with a clinical CBCL TPS were similar. As a result, the corresponding sensitivity and specificity parameters were very different, whereas the AUCs were quite comparable. We concluded that the sensitivity and specificity based on the original cut-off points were of no use to compare the screening qualities of the three questionnaires. We therefore defined new, more comparable cut-off points, namely those scores that were associated with a specificity of at least 0.90 in our sample. These new cut-off point lead to 16% elevated scores on the PSC and the SDQ and 17% elevated scores on the PSYBOBA.

Third, we assessed the added value of the instruments: to what extend do they offer new information, compared to information on possible risk factors, available from PCH files. These variables are listed in Table 1. In multivariate logistic regression only gender, family composition and ethnic background showed a significant association with a clinical TPS. We performed logistic regression analyses to predict a clinical and borderline TPS, using these variables as predictors. Then we added the elevated scores to the model and checked whether this improved the prediction. This is comparable to what we did in two earlier studies [14,15]. We extended these analyses and also used the question whether the PCH professional had detected any problem (yes or no) as a predictor in the model, before entering the elevated scores. The height of the odds ratio (OR) for elevated scores was used to measure the added value each questionnaire offered.

Finally, the usability of the questionnaire in daily practice was assessed. For parents, differences in response rate, item non-response, and opinions on difficulty and length and the number of critical remarks were tested with ANOVA and Chi2-tests. For PCH professionals' opinions on usability we counted the number of optimal ratings over the individual health assessments for which each questionnaire was used. The comparative ratings of the questionnaires by PCH professionals were inspected and described. No tests were done on these data, as only nine PCH professionals participated in the pilot.

Unless otherwise specified, analyses were done with SPSS 12.

Results

Scale Structure

The internal consistencies of the total problem scales of the three questionnaires were very satisfying: 0.  Table 2 lists the items with low regression weights (≤ .33) in the single scale models. For the SDQ a more subtle model was evaluated, reflecting the questionnaire's subscales. PGFI was 0.74 and RMSEA = .064 (.060 -0.68). This model may be considered as approximating a fit. Table 3 presents data on the validity of the three questionnaires, using a clinical and borderline TPS as criterion, for all children and for children who never were treated for any psychosocial problem in the past. Each of the questionnaires was highly correlated with the CBCL TPS. Both the product moment correlation coefficients and the kappa's were quite comparable. The table also presents the adjusted cut-off points used, when calculating kappa, sensitivity and specificity. Differences between the three questionnaires were small. We repeated the analyses for cut-off points which would result in a specificity of at least 0.95. This cut-off point would result in a sensitivity for a clinical TPS of 0.73 for the SDQ, 0.67 for the PSC and 0.62 for the PSYBOBA. Again, no significant differences were found.

Validity

Excluding children who had been under treatment resulted in almost identical sensitivities and specificities. Using a borderline TPS as the criterion resulted in somewhat lower sensitivities.

Added Value

Three demographic variables showed a significant association with a clinical TPS: gender, ethnic background and family composition. These variables were included in a logistic regression model as possible predictors of a clinical or borderline/clinical TPS. Adding elevated scores to the model resulted in a significant (p < .001) and substantial improvement of the models for each of the three questionnaires.  Table 4 presents the results of the extended added value analyses, in which problems as detected by the PCH professionals were also included in the model. PCH identified 27% children with a psychosocial problem. The ORs in these extended added value analyses are lower than those in the simple added value analyses, which suggests that part of what is detected by the questionnaires, was also identified by PCH professional without the aid of questionnaires. Yet, in all analyses adding the elevated scores to the model resulted in a very significant (p < .001) improvement of the prediction. The differences between the questionnaires were not significant.

Usability -Parents

The response rate for the SDQ (87%) was slightly higher than for the PSYBOBA and the PSC (both 84%) (Chi 2 = 22.5, df = 2, p < 0.01). The PSC showed the highest mean number of unanswered questions (n = 0.26), compared to 0.06 for the PSYBOBA and 0.05 for the SDQ (F = 7.4, df = 2, 2076, p < 0.001).

Parents' ratings of length, and difficulty of the questionnaires showed significant but small differences between the questionnaires (see Table 5). Twelve percent found the PSYBOBA long or too long, compared to 20% for the PSC and 19% for the SDQ. The percentage of parents rating the questionnaires as difficult varied between 41% (PSC) and 31% (PSYBOBA). Finally, 20% of the parents had criticisms on the PSC, compared to nine percent for the PSY-BOBA and ten percent for the SDQ. They criticized the  ambiguity of some questions (e.g. "Spends more time alone ..." without specification of how to compare) and the discrepancy between items and answering categories (e.g. "School grades dropping" to be answered with never, sometimes, or often).

Usability -PCH Professionals

PCH professionals rated the three questionnaires on 9 aspects after using them during about 76 examinations.

The mean number of optimal ratings was highest for the PSC (6.0 out of 9). For the PSYBOBA it was 5.6 and for the SDQ 4.5 (Table 6). This difference is significant (F = 25.2, df = 2, 241, p < 0.001). The largest differences were found on items referring to the complexity of the calculation of scores, mainly concerning the SDQ's subscales.

After completing routine examinations with all three questionnaires, PCH professionals rated the question-  naires on a scale from 0 till 10. Mean rating for the SDQ and the PSYBOBA was 6.3, higher than that for the PSC (5.5). When asked which questionnaire they would like to use in the future, four of the eight PCH professionals chose the SDQ, two the PSYBOBA and only one the PSC. One PCH professional did not make a choice.

Discussion

This study compared three questionnaires (SDQ, PSC and PSYBOBA) in order to decide which was most suited to improve identification of psychosocial problems among children aged 7 till 12 in community health services. The internal consistency of the overall scales was high. The construct validity of the three questionnaires was highly comparable. All questionnaires had a satisfactory sensitivity, at a specificity of 0.90, for problems defined as a clinical TPS score and a somewhat lower sensitivity for problems defined as a borderline TPS score. All three questionnaires offered substantial added value, improving the identification of children with problems based on readily available health indicators and/or clinical assessment during routine examinations. Due to the simplicity of score calculation, the PSC was rated more favourably by nine PCH professionals, for use in daily practice. Yet, in an overall rating by these professionals the PSC was rated less favourably than the SDQ and PSYBOBA.

The PSC resulted in a higher item non response and one in five parents had some criticisms on the PSC. We know no other studies mentioning such problems with the PSC. Yet, we do not think that these problems are to be explained by our translation. Many remarks concerned ambiguities (e.g. 'Is less interested in school': less than who or when?) and inconsistencies between the questions and the options for answering ('Gets hurt frequently' to be answered by 'never, sometimes or often). These ambiguities and inconsistencies are also part of the original questionnaire.

An essential element of the design of this study is that it used randomisation and aimed at a comparison of three questionnaires. We know of no other studies that used a similar design. Our approach is comparable to what is now rapidly becoming standard in studies assessing effectiveness and economic evaluations of interventions. Such studies do not assess the effectiveness or costs as such, but compare specific interventions with other interventions or usual care. Such an approach is far more helpful in guiding health policy decisions. We feel that such a comparative approach is worthwhile, too, in the evaluation of questionnaires to be used in health care. Only a systematic comparison can guarantee that the best instrument available will indeed be chosen. Data were collected using a methodology that closely resembles the way Dutch PCH works, i.e. the questionnaires were sent to the parents, together with the invitation for a regular check up of their child. This improves the external validity of our results. However, one caveat is important: the main aim during sampling was to guarantee similarity between the three sub-samples, not an overall representativeness for the Dutch population. This resulted in a clear underrepresentation of ethnic minorities, caused by a higher nonresponse rate and non-participation of PCH services of the three largest cities in the Netherlands,. The results therefore need confirmation among ethnic minorities.

We used the CBCL as criterion. Although the CBCL is one of the best instruments available and is often used for evaluation purposes, it cannot be regarded as the ultimate golden standard. Other studies used psychiatric interviews or assessments by mental health professionals as standard [8]. Due to financial limitations this was not possible in this study.

The absence of an ultimate golden standard means that the results of the study should be interpreted carefully. The high convergence between the three questionnaires and the CBCL indicates that they can be used as a valuable tool, supporting the professional's assessment and alerting him to probable cases. Yet, it seems unwise to use these short questionnaires as selection tools, limiting further assessment only to those children with elevated scores. The risk of missing serious problems would be too great. The questionnaires are valuable tools to alert PCH professionals on likely cases when they asses psychosocial problems. However, the PCH professional should also include other sources of information: his/her interview with both the parent and the child, the observation of the child and the parent-child interaction, and ratings from teachers whenever possible. Also, the impact of problems on the child's or family's functioning should be taken into account before deciding on further action. The SDQ provides such information in the Impact supplement.

In this study we had to use other cut-off points than those reported in the literature because the latter resulted in large differences regarding the percentage of children with an elevated score. This may raise the question whether these instruments measure the same construct. We think that this is the case indeed, as we found very comparable convergence indices with the CBCL TPS, both for the total scores on each of them and for the proportions with elevated scores based on the adapted cut-off points.

Our data on the validity and reliability of SDQ and the PSC are comparable to those published by other authors [10,11,[28][29][30]37]. We found, however, no other studies which question the scale structures of these questionnaires. Probably, our choice for the rigorous SEM as analytical tool instead of the more usual factor analytical approaches is the key factor. The combination of high internal consistencies and the negative SEM results may come as a surprise. What the SEM analyses showed, however, is that the concepts, as implied by the (sub)scale scores, despite the internal consistencies, are an inadequate description of the way the items are related to each other. In other words: the items provide information not covered by the scale scores. Health care providers should therefore not rely on the scale scores alone, but also carefully check the answers on individual items and discuss these answers with the parents.

Few studies assessed the added value of using questionnaires, as we did. The only studies to compare our results with are our own evaluations of two other questionnaires, that assessed the added value of questionnaires, as compared to risk indicators [14,15]. In the current study we extended the added value analyses, by also including the signals detected by PCH professionals during routine examinations into the analysis. These extended analyses give a better indication of the real added value, as they compare the quality of questionnaire based detection to what is now standard practice for this age group, at least in the Dutch health care system.

Which of the three questionnaires, then, would be the best choice? The sensitivity of the PSC was somewhat less than that for the other questionnaires. The added value of the PSC in detecting children with clinical TPS was relatively low. One in five of the parents had criticisms on the PSC and item non response was also higher. In the Netherlands, the PSC would therefore be an unlikely choice. The psychometric performance of the PSYBOBA and the SDQ were similar. Although more PCH professionals preferred the SDQ as the instrument to use in the future, it was rated less positively in practical use, mainly because by the relative complexity of calculating the (sub)scale scores. We found little support for the supposed scale structure but also found that the SDQ Total Problems score is a strong indicator of problems. When the primary aim is to make a first distinction between children who probably have problems that need attention and those who do not, the single SDQ Total Problems score suffices. This largely simplifies the use of the SDQ.

Conclusions

This randomized comparison of three questionnaires showed that all three questionnaires can improve the detection of psychosocial dysfunction among children substantially. The PSC elicited more critical remarks from the parents than the SDQ and PSYBOBA and showed a higher item non-response.

80 for the SDQ, 0.87 for the PSYBOBA and 0.89 for the PSC. The differences in Cronbach's alphas could be completely explained by the differences in number of items: applying the Spearman Brown Prophecy Formula resulted in exactly the same corrected α's. Internal consistencies for the SDQ subscales varied between 0.55 and 0.78. Structural equation modelling showed an unsatisfactory fit of the single scale models with the data (SDQ: PGFI = 0.66; PSC: PGFI = 0.66; PSYBOBA: PGFI = 0.65). RMSEA indices and their 90% confidence intervals were respectively .099 (.094 -104), 079 (.076 -082) and092 (.088 -096), suggesting a mediocre fit for the SDQ and PSYBA and an approximation of fit for the PSC[36].

Table 1 :
1Characteristics of the respondents and non-respondentsResponse %
Non-response %

not under treatment, the ORs were lower but still substantial, ranging from 46.3 till 71.8. The difference, again, were small in relation to the 95% confidence intervals.The Adjusted ORs for all children were:
PSYBOBA: 89.3 (38.0 -210.6); PSC: 35,6 (17.8 -71.4)
and SDQ: 71.7 (30.7 -167.4). All 95% confidence inter-
vals of the ORs overlapped with each other. For children

Table 2 :
2Items with low regression weights # in the single scale SEM analysesQuestionnaire
Items

SDQ
6
Rather solitary, tends to play alone
11
Has at least one good friend
22
Steals from home, school or elsewhere

PSC
1
Complains of aches and pains
2
Spends more time alone
3
Tires easily, has little energy.
15
Less interested in friends
17
Absent from school
20
Visits the doctor with doctor finding nothing wrong
34
Takes things that do not belong to him or her

PSYBOBA
4
Has friends
7
Dares to stand up for him/her self
13
Is often still or withdrawn
14
Often complaints about pain
15
Is open about what is bothering him/her

# β ≤ 0.33

Table 3 :
3Validity of the questionnaires, using a clinical and borderline CBCL TPS as criteriaPSYBOBA
PSC
SDQ

Table 4 :
4Odds ratios of the elevated scores on the three questionnaires for a clinical and borderline TPS score, adjusted for gender, ethnic background* and family composition* and Problems identified by PCH**PSYBOBA
PSC
SDQ

OR (95% CI)
OR (95% CI)
OR (95% CI)

Table 5 :
5Parents rating of the length and difficulty of the questionnaires, and percentage of parents with criticismsPSYBOBA
PSC
SDQ
Significance +

n = 796
n = 815
n = 814

Table 6 :
6Percentage of examinations resulting in an optimal rating by PCH professionals on nine questions on usability, by questionnaire usedPSYBOBA
PSC
SDQ

%
%
%

(page number not for citation purposes)
+: p < 0.05; **: p < 0.01; *** p < 0.001 †: Corrected for total number of items in each questionnaire; standardized for 25 itemsAcknowledgementsThis study was made possible by a grant from ZonMw, the Netherlands Organisation For Health Research and DevelopmentCompeting interestsThe authors declare that they have no competing interests.Authors' contributionsAll authors contributed to the design and execution of the study and the analyses. AGCV, MRC and SAR were actively involved in writing this manuscript. FH commented drafts presented to her.Publish with Bio Med Central and every scientist can read your work free of chargePre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/9/489/pre pub
AUC: Area under Curve; CBCL: Child Behavior Checklist. AUC: Area under Curve; CBCL: Child Behavior Checklist;

CI: Confidence Interval;OR: Odds Ratio; PCH: Preventive Child Health Care; PSC: Pediatric Symptom Checklist. CI: Confidence Interval;OR: Odds Ratio; PCH: Preventive Child Health Care; PSC: Pediatric Symptom Checklist;

PSYBOBA: Psychosociale Problemen Bovenbouw Basisonderwijs (Dutch for: Psychosocial Problems in Primary Education). SDQ: Strengths & Difficulties Questionnaire. PSYBOBA: Psychosociale Problemen Bovenbouw Basisonderwijs (Dutch for: Psychosocial Problems in Pri- mary Education); SDQ: Strengths & Difficulties Question- naire.

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A Qualitative study of language barriers between South African health care providers and cross-border migrants

Jo Hunter-Adams
Hanna-Andrea Rother
A Qualitative study of language barriers between South African health care providers and cross-border migrants
10.1186/s12913-017-2042-5R E S E A R C H A R T I C L E Open Access
Background: Communication with health care providers represents an essential part of access to health care for the over 230 million cross-border migrants around the world. In this article, we explore the complexity of health communication from the perspective of cross-border migrants seeking antenatal care in Cape Town, South Africa in order to highlight the importance of high quality medical interpretation. Methods: As part of a broader study of migrant maternal and infant nutrition, we conducted a secondary data analysis of semi-structured in-depth interviews (N = 23) with Congolese (n = 7), Somali (n = 8) and Zimbabwean (n = 8) women living in Cape Town, as well as nine focus group discussions (including men: n = 3 and women: n = 6) were conducted with migrant Somalis, Congolese, and Zimbabweans (N = 48). We first used content analysis to gather all data related to language and communication. We then analysed this data thematically. Results: Zimbabwean participants described how the inability to speak the local South African language (IsiXhosa) gave rise to labelling and stereotyping by healthcare staff. Congolese and Somali participants described medical procedures, including tubal ligation, which were performed without consent. Partners often tried to play the role of interpreter, which resulted in loss of income and non-professional medical interpretation. Participants' highlighted fears over unwanted procedures or being unable to access care. Challenges of communication without a common language (and without professional medical interpretation), rather than outright denial of care by healthcare professionals, mediated these encounters. Conclusion: Although there are several factors impeding cross-border migrants' access to health care, effective communication is a prerequisite for quality care. Free-to-patient professional medical interpretation would not only benefit migrant populations but would benefit the broader community where language and health literacy are barriers to accessing health care. Novel approaches to language access may include technology-enabled professional interpretation.

Background

In 2013, there were more than 232 million cross-border migrants globally [1]. Cross-border migrants have heterogeneous life experiences and travel for many different reasons. They may have experienced discrimination and marginality before, during, or after travel. Given the magnitude of international movement, facilitating healthy migration and providing high quality care to migrant populations needs to feature clearly in health policy and health systems. We focus on the challenge of providing quality care in the context of migration between low-and-middle-income countries, using South Africa as an example. While the notion of quality care has many facets, this article focuses on communication as an essential precursor for many aspects of health care quality, including considering medical advice and taking medicine correctly. Communication across language and cultural barriers has received much interest in certain settings, notably in the U.S. However, in low-and middle-income (LMIC) settings health communication tends to have low priority relative to other pressing issues in the health system. In this article we attempt to document the importance of communication for migrants seeking maternal care in Cape Town, South Africa.

Given stretched public health services, providing adequate access to health care services for all is a current challenge in South Africa. Migrants, however, face particular challenges that are often exacerbated in relation to accessing services. The South African constitution [2], the South African Refugees Act [3] and the right to basic health care (Section 27 (1) (a)) present ambitious standards for realising human rights and the dignity of all, including all migrant groups. However, in many cases government fails to provide services that live up to these standards for the general population. While recognizing that both migrants and South Africans face a complex slew of challenges in accessing health services (e.g., long wait times, medication shortages), in this paper we argue that language is a key obstacle to adequate medical care and health literacy. Particularly, we assess the impact of language barriers for crossborder migrants on accessing care, and understanding the implications of medical treatments recommended.

Post-apartheid, South Africa is an important destination country for African migrants seeking work and/or asylum. In Cape Town, cross-border migrants constitute at least 3% of the population, and may make up as much as 9%, due to large numbers of individuals' country of birth being listed as "unspecified" [4]. Yet cross-border migrants in South Africa continue to be marginalized and subject to a broad range of discrimination (e.g. violence against foreign-owned businesses, job discrimination) [5,6]. Experiences of exclusion are exacerbated by lack of legal status, as well as minority status relative to South African population groups. Despite evidence that urban migrants actually contribute to the economies of their new cities [7,8], cross-border migrants in South Africa continue to be portrayed as placing a burden upon the public healthcare system [9]. As Crush and Tawodzera [10] rightly point out from their research, xenophobia in South Africa can also be witnessed in the public health system which they refer to as "medical xenophobia". Examples of this include hospital security declining non-nationals entrance into a health facility, and health professionals placing non-nationals in a longer queue [10]. Language barriers and the lack of medical interpretation are further examples where migrants experience "medical xenophobia".

Methods

Fieldwork for this qualitative study was conducted between February and October 2013, and the findings presented in this paper are based on language issues raised during in-depth interviews and focus group discussions. The results presented in this paper are derived from a broader study of cross-border migrants experiences of maternal and infant nutrition in Cape Town, South Africa, where language and communication emerged as an unintended theme [11,12]. We hold to the constructionist tradition [13] that meaning and analyses are constructed rather than fixed, and this analysis represents a contribution to our understanding of patient experiences of multilingual medical encounters in a specific context of cross-border migration to a LMIC.

Study setting

The study was conducted across greater Cape Town. Cape Town is in the Western Cape province of South Africa where 28% of residents are not born in the province and up to 9% are born in another country [4]. The participants in this sample predominantly resided in rooms with their partner and children, sharing amenities with other families, either in a larger house or apartment, or in illegally subdivided warehouses. Most interviews took place in migrant homes, whereas focus groups took place primarily in more communal settings, including community centres, shops, and a women's shelter. While one focus group took place with residents of an informal settlement with shack housing, participants more commonly resided in inner city settings across many parts of Cape Town. Although the participants in this sample largely occupied these relatively crowded inner city spaces, it should be noted that crossborder migrants in Cape Town have a wide range of educational and socio-economic backgrounds, and have a broad range of professional roles in South Africa. The experiences of participants in this sample were thus grounded in a specific socio-economic context, in particular, of life in the inner city, and to a lesser extent, in informal settlements.

Study participants and sampling

Study participants were selected to participate either in in-depth interviews or in a focus group. Participants had typically resided in South Africa for less than 10 years. For the in-depth interviews, 23 Somali (n = 8), Congolese (n = 8), and Zimbabwean (n = 7) women were purposively selected to include different migrant groups who could provide diverse insights. The interview inclusion criteria was: women over the age of 18 who were pregnant or had given birth in the last 2 years, and self-identified as Somali, Congolese (from the Democratic Republic of Congo, DRC), or Zimbabwean. The majority of in-depth interview participants were married. Nine separate focus group discussions (N = 48) where held with adult Somali, Congolese, and Zimbabwean men (N = 3; n =21) and women (N = 6; n = 27), segregated by country of origin and gender. In the parent study, in-depth interviews were used to attain depth of knowledge about individual perceptions of maternal and infant nutrition, while focus groups provided perspectives on collective meanings and understandings-the collective narrative [14]-related to maternal and infant nutrition in Cape Town. Both indepth interviews and focus groups consisted of a convenience sample using snowball sampling, an effective technique among hard-to-reach populations [15], and used both non-governmental organization (NGO) contacts and individual introductions to begin meetings with eligible cross-border migrant participants. These NGOs worked across different parts of the city, with various populations. Including both in-depth and focus group discussions, there were 26 Congolese participants (16 women, 10 men), 21 Zimbabwean participants (16 women, 5 men) and 24 Somali participants (18 women, 6 men). More women than men were sampled due to the original study design which focused on maternal and infant nutrition. This may mean that more language issues were described, as women were less likely to have paid employment or to have had other opportunities to become conversant in English. Nevertheless, maternal care is also one of the key points of care for migrants, and thus language in the specific context of maternal care is an important issue for migrant health [16,17].

Data collection

JH-A conducted all the interviews and focus groups. Two focus group discussions, four Somali in-depth interviews and one Congolese in-depth interview also included a trained interpreter to assist JH-A. In-depth interviews lasted between 1 and 1.5 h, and were primarily conducted in participant homes. Focus group discussions took place in community centres and lasted between 1.5 and 2 h.

The objective of the broader study was to garner meanings and understandings and dominant discourses related to maternal and infant nutrition in a migrant context. An interview guide framed the semi-structured in-depth interviews [12]. When participants discussed health care it was frequently in relation to accessing healthcare during pregnancy, and how participants felt this related to feeding decisions. Questions in focus groups broadly related to comparing experiences of food provision and nutrition advice for pregnant mothers and new babies living in South Africa versus practices in participants' countries of origin. In this paper, the focus is on participants' unprompted discussions that related to language and healthcare provision in Cape Town public hospitals, as well as primary health care clinics.

Use of language interpretation in data collection

Our use of interpretation in this study has been briefly described in a previous publication [12]. Nevertheless, it is important to discuss in more detail issues of meaning and language related to the our research process, to make the multiple languages used in the study more visible and consider the implications related to conducting a study in multiple languages [18]. Interpretation was not clean-cut; in Cape Town there are multiple South African languages spoken by residents. Amongst Congolese migrants, participants often used multiple languages in a single conversation. As such, making meaning, and settling on specific choices of words in transcripts, involved much negotiation [19]. This negotiation began with the process of simultaneous interpretation, and weighing how to manage interviews alongside interpreters, who were situated as a type of bridge between the participant and the interviewer. In in-depth interviews, we found that trying to make interpretation overly formal circumscribed free conversation, while allowing the interpreter to be a third party in the conversation, made the participant more comfortable. Larkin and colleagues [20] termed this process "mutual reciprocity". Zimbabwean participants were comfortable using English in the interview setting, though they may speak English, Shona, and/or Ndebele amongst family and friends. Somali participants typically preferred to speak Somali, whereas Congolese participants preferred a mixture of languages (French and either Swahili or Lingala) or had become fluent in English through work or studies in Cape Town. Independent professional medical interpreters then checked the quality of interpretation (comparing audio to English transcripts), discussed the role of the interpreter, and discrepancies and alternative meanings with the moderator/interviewer (JHA). Transcripts were then revised and discussed with the independent professional interpreter to enhance the quality of the final "verbatim" transcript. We recognize that the process of speaking on behalf of any participant group, particularly when engaging in research, presents potential research limitations.

Data analysis

In this paper we focuses specifically on categories related to language and communication. These categories were identified during overall data analysis of the broader research question. The broader data analysis was guided by principles of thematic analysis [21,22]. This analysis began during fieldwork in the form of a research diary, notes, and reflections. After immersion in both focus group and interview transcripts through reading and rereading, an inductive initial analysis was used to generate a codebook and code all transcripts [23]. After developing and defining an initial set of codes, we began to code transcripts and test validity of the codes and the extent to which they seemed to convey the meanings and understandings presented by participants. Once no new categories of codes appeared, the codebook was considered complete and coding of all transcripts-both in-depth interviews and focus groups-were coded using the complete codebook. All transcripts were uploaded to the computer software Hyperresearch (Researchware Inc., 2009, Massachusetts, U.S.A.), to assist with coding, sorting, and data management.

Based on our analysis, language and communication in health care settings represented a key theme through which participants understood their experience of maternal and infant nutrition in Cape Town. As such, we performed additional content analysis [24] to focus specifically on instances involving language barriers. This represented a secondary data analysis design, and was conducted by the same researchers who designed, implemented, analysed, and reported on the primary data analysis [25,26].

Results

We frame our results around the fundamental issue of the language barrier resulting from the lack of a common language. This was by no means the only issue with accessing health care, but it was among the significant reasons that participants felt unable to get adequate care. The issue of language emerged as an unexpected result in the context of broader questions related to maternal and infant nutrition. Comments related to language were raised whenever participants spoke of South African health services. As healthcare services represented a relatively minor line of questioning in interviews, language discordance was raised an issue explicitly in a small number of in-depth interviews. However, it was also raised frequently the nine focus group discussions, where language and lack of communication evoked very strong feelings and was often spoken about spontaneously. As an important topic for participants, we felt that language and communication deserved further analysis.

Lack of a common language: Refusal to speak English

While reports of nurse abuse of patients is not specific to cross-border migrants [16,17], participants' perception of language as a vehicle of discrimination was exacerbated by participants' experiences of discrimination outside the healthcare system. For example, among Zimbabweans, participants' interpreted the language barrier as an unnecessary imposition: Nurses could speak English but tended to communicate in IsiXhosa, despite the fact that Zimbabweans could not understand this South African language:

When we go to the clinics for the check-ups, ne, some of the nurses they are Xhosa some are coloured, 1 they are different, especially if we meet' the Xhosa nurses' sometimes they can speak to them [Zimbabweans] in their language, of which we don't understand their language. If you speak to them in English they can ignore you. Or, they can shout at you. It is bad for us. Of course, just because we don't understand their language. (Zimbabwean Women's Focus Group)

The use of isiXhosa by medical support staff was also perceived as a vehicle whereby Zimbabwean participants felt they were discriminated against. For  Moreover, issues of language were raised in conjunction with challenges of being and feeling alone in Cape Town. The need for nurse advice was expressed as particularly important in the context of the social isolation experienced by young mothers.

If she's speaking in Xhosa, and she is giving me advice, how can I understand? When I don't speak Xhosa. How can I know how to raise that child, when I don't know!? Like, when it's a small child [young mother], 17, 20, it's your first child?! Like back home, there will be a big person, who will be teaching you how to bath the child, how to feed the child… But here' it's nurses who are going to teach you. (Zimbabwean Women's Focus Group)

Participants seldom referred to high-level providers, such as doctors (who may be more likely to communicate with them in English), and much more on the roles of lower and mid-level providers such as nurses, front-desk receptionists and similar "gatekeepers". For Zimbabweans, the fact that these staff spoke to them in Xhosa meant that they felt discriminated against by the healthcare system, unable to receive emergency care (ambulances), and unable to receive medical advice.

Lack of a common language: Preventing informed consent

Participants largely did not describe being turned away from antenatal care, yet where migrants had strongly negative perceptions of health care, these perceptions revolved around being forced to receive interventions that they did not consent to. Similar experiences were recounted by many participants, and seemed to colour their experiences of health care in South Africa. Language barriers were a major feature in these descriptions: I get good advice and bad advice here (laughter). Is another people, you know we come from French place, we didn't come from English place… we come from a French place. Now when you come here your English is too small, you don't know anything when you go to the hospital. The doctor… you're pregnant… you go to the hospital, […] they just ask you, you want to cut, you want to make family planning, you want to cut your tubes and you don't know what they are talking, you just say yes, but if you have paper you sign, you go. (Congolese mother of six children)

Multiple Somali participants-both in the men's focus group and in individual interviews-described cases in which Somali women were sterilized without consent. This story had reverberated throughout the community, leading women to be very fearful of and mistrust healthcare providers.

They came to her when she was sick, and she had no husband there, and told her to sign… and she had no idea what she was signing. And they did the process [tubal ligation]… and she can't deliver anymore, even permanently. So when they go there, to the hospital, to complain, they said "you signed", but she didn't understand, and she was sick. That's why I'm concerned. That's why I'm very concerned. (Pregnant Somali mother of five children, Interpreter present) While health care providers may perceive an offer of family planning advice as standard procedure, the lack of medical interpretation, together with women's marginality in Cape Town, meant that women felt coerced to receive interventions, or even that they received an intervention without knowing. These interventions, and the ways they were interpreted, take place against a backdrop of staff shortages and xenophobic violence in South Africa. However, without a means of communication, stereotypes and misunderstandings could not be challenged, resolved or discussed. For all three population groups, participants' experiences translated to an overall lack of trust in the healthcare system. In turn, this limited their ability and willingness to seek out advice of healthcare professionals more generally, and made them more likely to distrust whatever advice they did receive.

We highlight the experiences of one particular participant to illustrate the specific cascade of events that can occur when communication between provider and patient is inadequate. Halima 2 was a 26-year old Somalia pregnant mother of five who could not speak English. She described suffering from high blood pressure and gestational diabetes during previous pregnancies. Halima's first husband had been murdered in the South African xenophobic attacks of 2008. Approximately 6 months pregnant, she had not yet received any antenatal care fearing that she would be shouted at for becoming pregnant (a common occurrence described by Somali participants). During a previous pregnancy, she described being cautioned that if she returned pregnant, she would have a procedure to prevent her from becoming pregnant again.

I gave birth to some of my children at [hospital name], some at [hospital name], but the last time they told me, no this time, they gonna sew… something like tubes… I don't know… I am thinking of maybe going to [alternative hospital], because … [but] they might do that. Stop me for 5 years… and that's something I'm against. So I'm thinking of private hospitals, but I'm also thinking, it's too expensive! (Pregnant Somali mother of five children, Interpreter present) Describing a deeply antagonistic relationship with health care providers and concerned about stories of other Somali women who had reportedly undergone forced sterilisation, Halima was potentially putting herself at risk of health complications. She was alone with her children during the week as her husband worked running a small shop in an informal settlement. In previous pregnancies she had to go alone to medical appointments, and she was unable to speak English.

Halima describes "healer shopping" [27], where, finding it impossible to communicate her priorities and choices to providers, she started shopping around for a hospital that would not "know" her. She felt as though she had been blacklisted and was being punished for having children, rather than feeling that the health system wanted the best outcome for her. These fears were amplified by the stories of forced sterilizations that circulated within multiple migrant communities, including Somalis and Congolese. It was apparent that she and providers had to somehow communicate largely without language, and that the two-way communication necessary to convey health information as well as patients' concerns and interests, was lacking. From Halima's perspective, xenophobic health care providers did not want her to have children, and did not respect Somalis' practice of Islam, which precluded family planning except in the case of serious illness. Without communication between medical provider and patient, there was no opportunity for Halima to understand the risks related to high blood pressure and previous gestational diabetes, and in becoming pregnant again and arriving for antenatal care very late in pregnancy, it seemed likely that the negative cycle between provider and patient would be further entrenched.

Lack of a common language: Migrant responses

During all three men's focus group discussions, participants' described accompanying their wives and partners to appointments to interpret for them. Descriptions by English-speaking Congolese and Somali men revealed some of the complexity of juggling appointments, particularly in the context of work.

Assisting her because she didn't know English as well and she has to go, before she goes to hospital I have to write everything in a paper and when you go you have to say-give them the paper, he will read the paper. So when they do all the tests then I ask her also to ask the nurse to write in the paper so I can understand and explain to her at home […] I don't have anyone here like to assist and take her to hospital and I had a tough time at work as well because sometimes I have to excuse myself from work and take her to hospital, even when the child was born, ja, those are kind of difficulties we experience.

(Congolese Men's Focus Group)

It is common for family members to be used as ad hoc interpreters in the South African healthcare system, both for South Africans and non-South Africans. Whereas for South Africans, children, cleaning or health care staff are often described as playing the role of interpreter [28], for non-South Africans in this study, this role was placed on the male partner. This role was in turn viewed as a "burden" as expressed as a dominant theme in the Congolese and Somali focus groups.

Discussion

While much has been written about medical interpretation in high-income countries (HIC) [29][30][31], most notably in North America, South Africa is one of the only low and middle-income countries (LMIC) where studies of medical interpretation have taken place. Previously, the experiences of non-English speaking South Africans have been highlighted in the South African context, largely in urban settings such as Cape Town [28,32,33]. In South Africa, there is currently no official system for medical interpretation (where medical interpretation is the facilitation of communication between a medical provider and patient who do not speak the same language). Given that South Africa is a multilingual society with 11 official languages and many South Africans do not speak English, up to 80% of health care consultations in South Africa are carried out across linguistic and cultural barriers [34], and the language barrier has become normative and even invisible [28]. Yet the consequences of the language barrier has been to essentially "silenc[e] the patient's voice" (p58) [27]. It compromises patient quality of care, where those who cannot communicate with health care providers are less likely to adhere to treatment, to seek care or follow-up appointments, or receive preventive services [33].

The lack of professional medical interpretation affects adequate health care provision. Ad hoc interpretation or no interpretation results in misdiagnosis and the inability to understand or follow medical recommendations [27]. Interpretation by male partners in the case of cross-border migrants placed a financial burden on families who were made all the more vulnerable by spouses taking time off work. Where husbands were positioned as gatekeepers for their spouses' care, women were dependent and vulnerable. Moreover, the use of partners as ad hoc interpreters violated confidentiality and increased the likelihood of medical error. In one study based in the U.S., the use of ad hoc interpreters actually resulted in poorer communication than no interpretation whatsoever [35]. Whereas professional medical interpretation has been presented as prohibitively expensive, these costs must be weighed against the economic and other costs of medical error as well as the costs of ad hoc partner interpretation to an already financially marginal family unit. Medical interpretation needs to feature in a broader measure to improve health literacy among all living in South Africa.

Our study is suggestive of the experience of language discordance as a key hurdle impeding medical care between migrants and health care providers. The language barrier, however, is symbolic of deeper perceptions and attitudes of lack of trust. To the extent that the language barrier was an intentional imposition for English-speaking Zimbabweans, it presents an example of xenophobia, and adds to existing evidence of this phenomenon. In other cases, particularly for non-English speaking Congolese and Somali participants, the consequences of lack of a common language included lack of consent for medical procedures. This was closely linked to a lack of trust, resulting in a patient opting out of much-needed medical care. Lastly, the inability of cross-border migrants to communicate with health care providers led to untenable financial costs to the household in cases where family members were forced to miss work to accompany partners to appointments. In the long run, therefore, the lack of medical interpretation in this population could clearly affect the health outcomes of the patient, as well as the long-term medical costs of late entry into care, lack of ability to communicate symptoms, and lack of ability to follow medical advice.

The findings of this study demonstrate ways that professional medical interpretation may be a vital part of access to health care in cases where patient and provider lack a common language. The mismatch between the strongly worded human rights orientation of the South African constitution and the lack of capacity at a health systems level speaks to a core challenge of the South African health system in living up to the standards of the constitution. However, given that human rights motivation for medical interpretation is largely established [32], the question becomes one of practical application and financing, as well as one of political will and prioritization of health needs.

One practical barrier to interpreter services in settings where there is precedent for providing professional services has long involved the question of who should pay for interpreter services, given stretched resources. While this question is a challenging one, it is important to note that there is evidence to suggest that providing interpreter services greatly increased uptake of preventive visits [30], and that the provision of interpreter services makes patient visits much more efficient, saving money in the long term [31]. In a study of interpretation in the United States, patients with low English proficiency (LEP) who did not receive professional medical interpretation were hospitalised for significantly longer and were significantly more likely to be readmitted within 30 days [29]. A second study found that LEP patients received significantly more preventative services, more office visits, had more prescriptions filled when they had professional medical interpretation during medical visits [30]. Moreover, the financial cost to families who provide ad hoc interpretation to spouses has ethical and financial costs, increasing the likelihood of medical error [35] and resulting in a potential loss of earnings. In the South African context, an argument can and should be made that increased costs related to medical interpretation may be offset by the lower costs of improved adherence, reduced hospital stays in the public health system, and ultimately, better health outcomes. Given that medical interpretation is a global issue, interpretation may involve collaboration between trained bilingual individuals in migrants' country of origin. For example, the use of skype calls may be a potentially affordable means to facilitate communication in cases where there are few truly bilingual individuals in the new country.

Although medical interpretation represents an important step to improve health communication through addressing language barriers, it may not necessarily address the more deep-seated xenophobic attitudes. Who does the medical interpretation, however, must be considered so that trust of the interpretation is shared both on part of the migrant patient and the health care provider. Medical interpretation should therefore feature more prominently both as part of medical education and government health policies.

Limitations of the study

This study represents the perspectives of purposively selected participants of three specific nationalities living in Cape Town although there are other migrant populations. As such, it is both population and geographically specific. Our methodology of secondary data analysis of indepth interviews and focus groups also presents limitations to the broader applicability of our findings, as the data was derived from limited communication-related questions. Language barriers were not the specific focus of this study and so further probing and questioning was limited. That said, perspectives on language reached saturation, as diverse participants attending multiple health facilities expressed similar sentiments around lack of communication. Further studies of language discordance may require larger, more diverse samples in order to better understand the extent of this issue in South Africa, and elsewhere. Evaluation and discussion of existing language-based interventions in low-and middle-income settings would assist the development of appropriate responses.

Strengths of the study

This study represented one of the first efforts to understand the experiences of cross-border migrants in healthcare settings in Cape Town. As a group that is potentially vulnerable to poor health care and poor health, given xenophobia, lack of legal status, as well as other factors, understanding these experiences represents an important first step in improving migrants' health.

Conclusions

While in this article we focused on the South African case, issues of communication between health care professionals and cross-border migrant patients are global. Freeto-patient medical interpretation is one key intervention to address language barrier between health care providers and patients. In South Africa, advocating for such a service on a wide scale may first need to establish two things. Firstly, advocates need to establish that interpretation improves health outcomes, which to an extent has already been established, both in South Africa [32], and elsewhere [30]. Secondly, it must be established that professional medical interpretation is practical and implementable at a health systems level. For this, cost-effectiveness studies may help to make the financial case for the importance and feasibility of professional medical interpretation in South Africa. Given the limitations of the South African public health system, and numerous competing priorities, implementation at a health systems level is challenging. Remote interpretation, either via phone or videoconferencing, may provide a cost-effective alternative to in-person interpretation, where language volume in a particular geographic location is low [36]. Such an approach may be feasible in urban contexts such as Cape Town. In South Africa, piloting medical interpretation with a specific cross-border migrant group where a clear need has been demonstrated, at one or two hospitals, could pave the way for interpretation for other migrant groups, as well as South Africans.

The broader challenge of xenophobia, both in medical settings and in communities, may partially be addressed by better communication, to the extent that xenophobia is rooted in ignorance, although xenophobia also represents a deeply rooted systemic challenge. However, there is also a need to sensitise health care providers and frontline staff to the needs of migrants, as well as to dispel negative stereotypes of cross-border migrants. Longer-term measures to address these through the medical education system and health care policies are needed. Endnotes 1 The term "coloured" has roots in apartheid racial categories, and refers to individuals of mixed ancestry, including European, African and Asian ancestry.

2 Not her real name

example, study participants described calling for an ambulance and it not showing up, and feeling that if: You can give the Xhosa [person] the phone, to phone, right there the ambulance would come. Within 20, 30 minutes the ambulance would come…[…] but [for us] the ambulance didn't come. Until when I reached here, I found that the baby was delivered here in the house. Ja. So it's very hard. (Zimbabwean Women's Focus Group)
AcknowledgementsGratitude goes to Anna Strebel, Marion Heap, and Di McIntyre, who made valuable comments on an earlier draft of the paper. Gratitude also goes to Landon Myer, who co-supervised the dissertation from which this paper was derived. Thank you to the two peer reviewers, whose comments greatly improved the quality of the paper.FundingThe National Research Foundation of South Africa provided an NRF Scarce Skills grant, which constituted scholarship funding for the dissertation of which this study was derived. Financial assistance for fieldwork was received from the South African Research Chairs Initiative (Chair in 'Health and Wealth') of the Department of Science and Technology and National Research Foundation of South Africa. (Any opinion, finding and conclusion or recommendation expressed in this article is that of the author and the NRF does not accept any liability in this regard.)Availability of data and materialsThe qualitative transcripts from which this study is drawn will not be publicly shared, as full transcripts cannot easily be fully anonymous, and confidentiality was precondition of the informed consent process.Authors' contributions JHA designed and implemented the study, and wrote the first draft of this paper. HR had a supervisory role throughout the design and implementation phases of the study, and substantially contributed to several stages of the drafting of this paper. Both authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publication Not applicable.Ethics approval and consent to participate Ethics approval for this study was granted by the University of Cape Town, Faculty of Health Sciences, Human Research Ethics Committee (Ref 009/ 2013). All participants provided written consent and were offered the opportunity to decline or opt out of the interview or focus group.• We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal Submit your next manuscript to BioMed Central and we will help you at every step:
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