Access to Mental Health Care Service for China’s Minority Patients and Foreign Patients with Limited Mandarin Proficiency (LMP) Wen Ren, Prof., PhD, Sichuan

Access to Mental Health Care Service for Chinas Minority Patients and Foreign Patients with Limited Mandarin Proficiency (LMP) Wen Ren, Prof., PhD, Sichuan University, China [email protected] April 9, 2015 ----Mental Health Center of West China Hospital, Sichuan University as a case study Sichuan University

I am here! Chengdu Sichuan Province

Contents Chinas linguistic and cultural diversity Some culture-related mental illnesses among some ethnic minorities Improved institutional support for mental health care Access to mental health care services for LMP Patients in China Existing and Prospective Good Practice Sichuan University

CHINA 1 2 3 4 56 ethnic groups & 1.4 billion people; 55 minority groups, less than 9% of the population, but nearly 114 million in total. http://www.gov.cn/test/2012-04/20/content_2118413.htm M andarin is the only official language; 53 minority groups have their own languages; 60 million use them, 60% of the total minority population. M ost Tibetans, Vygurs, Mongolians, Kazakhs and Koreans live in mountainous areas, border areas, and relatively underdeveloped areas. T ibetan, Vygur, Mongolian, Kazakh, Korean languages, all have high vitality value (equivalent to 56-71% of that of mandarin), each with over 1 million speakers 1.1 China, a multi-ethnic and multilingual country I. Chinas linguistic and cultural diversity Dao Bu, 2005 White Paper on Chinas Ethnic Policy and Common Prosperity of All Ethnic Groups

Mongolians Vygurs Tibetans Koreans Kazakhs I. Chinas linguistic and cultural diversity

REGION TOTAL (10,000 PERSON) MEETINGS / BUSINESS SIGHTSEEING /LEISURE VISITING RELATIVES & FRIENDS WORKER & CREW OTHERS TOTAL2636.08539.57892.9960.33328.54814.66 ASIA1636.15300.51541.3215.73238.75539.84 AMERICAS310.6555.91113.2925.9018.7596.80 EUROPE548.41147.70194.799.0761.80135.06 OCEANIA81.0114.4627.579.223.6626.10 AFRICA59.6920.9715.960.405.5716.79 C hina has about 26 million foreign visitor arrivals in 2013 and 2014. 1.2 China, a non-immigrant country, but one of the most visited countries in the world nowadays I. Chinas linguistic and cultural diversity Reference from: http://www.cnta.gov.cn/html/2015-2/2015-2-2-10-54-94590.html

I. Chinas linguistic and cultural diversity Based on the data of the 2010 census: the number of foreign residents in China reached about 600,000.

2. Some culture-related mental illnesses among some ethnic minorities 2.1 Alcohol dependence Traditional love of and tolerance to drinking Economic and social transformation

2. Some culture-related mental illnesses among some ethnic minorities 2.1 Alcohol dependence Inadequacy of medical resources & misconception about alcohols medicinal value Guo et al, 2003(11) It is believed in some minority areas that alcohol can ease pain and fatigue, treat insomnia, and cure rheumatism.

2.2 Depression Religion-related causes Tibetans as a relatively more male- centered community 2. Some culture-related mental illnesses among some ethnic minorities

3. Improved institutional support for mental health care L aw of the Peoples Republic of China on Mental Health adopted in 2012 covering 50-90%

3. Improved institutional support for mental health care In theory there should be a psychiatric department in a general hospital or a mental health hospital at or above county level. In practice this is not always attainable, especially in mountainous areas, border areas, and relatively underdeveloped minority areas where minority people live in mixed or compact communities.

4. Access to mental health care services for LMP Patients in China 4.1 General situation resources constraint Total health care expenditure in 2013: 3.2 trillion, or $51 million, 5.57% of GDP, but very small on a per capita basis. (Health Care Statistics Yearbook 2014) Resources unevenly distributed, highly concentrated and overused in large hospitals in big cities. (http://health.sohu.com/20140414/n398180766.shtml )http://health.sohu.com/20140414/n398180766.shtml

4. Access to mental health care services for LMP Patients in China 4.1 General situation insufficient language services offered by hospitals for LMP patients Major public hospitals in mega cities have Mandarin and English websites, but no information indicating provision of interpretation service; Some of them organize English training classes for staff, or invite speakers to lecture on interpretation-related knowledge and skills; The major hospitals in Xinjiang and Inner Mongolia have Vygur and Mongolian languages respectively in addition to Mandarin for their official websites. But no Tibetan languages are found on the official websites of major hospitals in Tibet.

4. Access to mental health care services for LMP Patients in China 4.1 General situation insufficient language services offered by hospitals for LMP patients A few private expensive hospitals in some mega cities may have full time or part time medical interpreters, but these are only exceptional cases. Clifford Hospital in Guangzhou, 11 full time professional medical interpreters, 4 language combinations. (Zhan, 2013)

West China Hospital, SCU The largest comprehensive hospital in China (with 10,000 staff members and 4,300 beds); Received about 5 million outpatients, inpatients and patients for emergency treatment in 2014. http://www.cd120.com 4.2 Mental Health Center of West China Hospital, SCU 4. Access to mental health care services for LMP Patients in China

Mental Health Center of West China Hospital, SCU It houses an outpatient section (including a rehabilitation center) and several inpatient wards with 200 beds. It has about 60 physicians that receive over 200,000 outpatients and over 6,000 inpatients, and provide psychological counseling to about 10,000 persons per year. http://www.cdxinli.com/ 4.2 Mental Health Center of West China Hospital, SCU 4. Access to mental health care services for LMP Patient in China

In modern hospitals practice, especially in public medical institutions, physicians are under enormous economic pressure to see as many patients as possible in as short a time as possible. Davidson, 2001 4. Access to mental health care services for LMP Patients in China

4.3 Access to mental health care services for Chinas LMP minority patients (with Tibetans as an example) and foreign patients at MHCWCH 4. Access to mental health care services for LMP Patients in China Patients own (mis)understand- ing of mental illnesses Hospital registration and visits

Mental Health Center of West China Hospital, SCU 4.3 Access to mental health care services for LMP patients in China 4. Access to mental health care services for LMP Patients in China Data from interviews at MHCWCH, SCU

4. Access to mental health care services for LMP Patients in China Profession (medical) interpreter: any individual paid and provided by the hospital or health system to interpret; training ranged from on-the-job training to formal 40-hour training in medical terminology and skills specific to interpreting in the medical setting. Ad hoc interpreter: an untrained person who is called upon to interpret, such as a family member interpreting for her parents, a bilingual staff member pulled away from other duties to interpret, or a self-declared bilingual in a hospital waiting-room who volunteers to interpret. (Karliner et al, 2007) Language mediation in doctor-patient communication: professional medical interpreter vs. ad hoc interpreter

4. Access to mental health care services for LMP Patients in China Profession medical interpreters: so far not provided at MHCWCH, SCU Professional interpreters : if any, hired by patients (mostly Chinese/English) Language mediation in doctor-patient communication: professional interpreter

4. Access to mental health care services for LMP Patients in China Patients bilingual family members, relatives, friends, colleagues, etc. Bilingual hospital staff members (either called upon to do direct consultation or help with interpreting) Volunteers : A. self-declared bilinguals in a hospital who volunteer to interpret; B. chance helpers; C. trade-off helpers. Patients and physicians/nurses struggling alone with gestures Language mediation in doctor-patient communication: Ad hoc interpreters and other forms of mediation

4. Access to mental health care services for LMP Patients in China Live interpreting Telephone interpreting Language mediation in doctor-patient communication: Formats of interpreting

4. Access to mental health care services for LMP Patients in China Cultural issues in doctor-patient communication StigmaCulturally sensitive topics

4. Access to mental health care services for LMP Patients in China Cultural issues in doctor-patient communication Its not about cultural differences only; it is also about how these differences may relate to certain mental illnesses, how these differences may affect peoples perception of mental health problems, and how these differences may affect access to resources, and what can be done to ultimately ensure equitable access.

4. Access to mental health care services for LMP Patients in China 4.4 Drawbacks of using untrained bilinguals or ad hoc interpreters Errors in comprehension and expression Low efficiency Improper involvement Confidentiality at risk Reduced patient trust and satisfaction Ambiguity of responsibility ( Ramirez 2003, Bloom et al 2005, Karliner et al 2006, Bauer et al 2010, Seidelman et al 2010 ) Errors in comprehension and expression Low efficiency Improper involvement Confidentiality at risk Reduced patient trust and satisfaction Ambiguity of responsibility ( Ramirez 2003, Bloom et al 2005, Karliner et al 2006, Bauer et al 2010, Seidelman et al 2010 )

P atients rank the need for free quality interpreting services as top priority P hysicians echo the need for language matching: Language concordance. Trained interpreters. 4.5 Physician/patients response 4. Access to mental health care services for LMP Patients in China

4. Access to mental health care services for LMP Patients in China Using professional interpreters leads to better health status assessment, improves access and quality of care, increases client trust and rapport with service provider, enhances patients ability to understand and follow doctors advice, raises consultation efficiency, ensures patient satisfaction, minimize doctor-patient disputes, and ultimately reduces cost for the medical system. ( Ramirez 2003, Bloom et al 2005, Karliner et al 2007, Tribe et al 2009, Bauer et al, 2010, Seidelman et al 2010 ) Using professional interpreters leads to better health status assessment, improves access and quality of care, increases client trust and rapport with service provider, enhances patients ability to understand and follow doctors advice, raises consultation efficiency, ensures patient satisfaction, minimize doctor-patient disputes, and ultimately reduces cost for the medical system. ( Ramirez 2003, Bloom et al 2005, Karliner et al 2007, Tribe et al 2009, Bauer et al, 2010, Seidelman et al 2010 ) 4.6 Benefits of using professional (mental) health care interpreters

Conclusion In the resources constrained context, attention is often given to the quantity of the mental health patients to be treated rather than the quality of care they receive; When it comes to CALD patients with mental illnesses, the need to address their language and cultural concerns and the need to provide quality care should be one and the same. Theres still a long way for us to go before language provision becomes part of the mental health care service provision, and the difficulty lies with both the financial and the cognitional.

Sichuan University

Bauer, A. M. & Alegria, M. (2010). The impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv., 61(8): 765-773. Cheng, y. Speculation and exploration on opening the optional course of medical interpretation in medical institutes. Researches in Medical Education, 2010(6): 836-839. Dao, B. The language vigor, language attitude and language policy. Academic Exploration 2005 6 :95 101. Davidson, B. (2001). Questions in cross-linguistic medical encounters: the role of the hospital interpreter. Anthropological Quarterly. 74(4): 170-178. Guo, W., et al. Alcohol addiction, a problem that shouldnt be ignored in cultural transformation-a survey to the alcohol drinking in some minority areas. Todays Ethnic Groups. 2003(11): 40- 43. Karliner, L.S., et al. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency: A systematic review of the literature. HSR: Health Services Research. 42(2): 727-754. Khawaja, N. et al. (2013). Characteristics of culturally and linguistically diverse mental health clients. Advances in Mental health. 11(2): 172-187. Masland, M. C., Lou, C & Snowden, L. (2010) Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings. Telemedicine and e-Health, Vol. 16(6): 739-745. Nie, W., Chen, X. & Bai, Y. On the model of training medical translators and interpreters in MTI programs, Foreign Studies, 2013(2): 89-94. Seidelman, R. D. & Bachner, Y. G. (2010). That I wont Translate! Family medical interpreter in a multicultural environment. Mount Sinai Journal of Medicine, 77:389-393. References

Sichuan University Tribe, R & Lane, P. (2009). Working with interpreters across language and culture in mental health. Journal of Mental Health. 18(3): 233-242. Zhan, C. & Yan, M. Status Quo, Problems and Future development of Medical Interpreting in China: A Study of Medical Interpreting Activities in Guangzhou Area, Journal of Guangdong University of Foreign Studies, 2013(3): 47-50) http://www.cd120.com http://www.cnta.gov.cn/html/2015-2/2015-2-2-10-54-94590.html http://www.cdxinli.com/ http://www.clifford-hospital.org.cn/ http://www.gov.cn/jrzg/2012-10/26/content_2252122.htm http://www.mzb.com.cn/html/Home/report/105836-1.htm http://www.pumch.cn/ References

Sichuan University

Existing and Prospective Good Practice of Mental Health Care Provision to LMP Patients in China in Resource Constrained Contexts Existing good practice Help train Tibetan physicians; Use physicians/nurses who can speak the patients language (now mostly English); Set up a special liaison office (with the help of the Chengdu Office of TAR government) for coordination work; Encourage mutual help among patients and their relatives/friends; Use telephone interpreting 5. Existing and Prospective Good Practice

Existing and Prospective Good Practice of Mental Health Care Provision to LMP Patients in China in Resource Constrained Contexts 5. Existing and Prospective Good Practice Prospective good practice Educate minority people with basic mental health related knowledge; Enroll ethnic minority students to study at medical schools who are willing to go back to their hometown upon graduation; Recruit physicians/nurses who can speak a minority language or a foreign language; Set up medical/health care interpreting programs in universities; Include interpreting courses in the curriculum for medical/psychiatry students

Existing and Prospective Good Practice of Mental Health Care Provision to LMP Patients in China in Resource Constrained Contexts 5. Existing and Prospective Good Practice Prospective good practice Work with T/I service providers Use communication technologies

Sichuan University Bauer, A. M. & Alegria, M. (2010). The impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv., 61(8): 765-773. Cheng, y. Speculation and exploration on opening the optional course of medical interpretation in medical institutes. Researches in Medical Education, 2010(6): 836-839. Dao, B. The language vigor, language attitude and language policy. Academic Exploration 2005 6 :95 101. Davidson, B. (2001). Questions in cross-linguistic medical encounters: the role of the hospital interpreter. Anthropological Quarterly. 74(4): 170-178. Falkenstein, S.(2004). An evaluation of mental health services for culturally diverse. Journal of Social Work in Disbility and Rehabilitation. 3(3): 53-74. Guo, W., et al. Alcohol addiction, a problem that shouldnt be ignored in cultural transformation-a survey to the alcohol drinking in some minority areas. Todays Ethnic Groups. 2003(11): 40- 43. Karliner, L.S., et al. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency: A systematic review of the literature. HSR: Health Services Research. 42(2): 727-754. Khawaja, N. et al. (2013). Characteristics of culturally and linguistically diverse mental health clients. Advances in Mental health. 11(2): 172-187. Masland, M. C., Lou, C & Snowden, L. (2010) Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings. Telemedicine and e-Health, Vol. 16(6): 739-745. Nie, W., Chen, X. & Bai, Y. On the model of training medical translators and interpreters in MTI programs, Foreign Studies, 2013(2): 89-94. References

Sichuan University Seidelman, R. D. & Bachner, Y. G. (2010). That I wont Translate! Family medical interpreter in a multicultural environment. Mount Sinai Journal of Medicine, 77:389-393. Tribe, R & Lane, P. (2009). Working with interpreters across language and culture in mental health. Journal of Mental Health. 18(3): 233-242. Zhan, C. & Yan, M. Status Quo, Problems and Future development of Medical Interpreting in China: A Study of Medical Interpreting Activities in Guangzhou Area, Journal of Guangdong University of Foreign Studies, 2013(3): 47-50) http://www.cd120.com http://www.cnta.gov.cn/html/2015-2/2015-2-2-10-54-94590.html http://www.cdxinli.com/ http://www.clifford-hospital.org.cn/ http://www.gov.cn/jrzg/2012-10/26/content_2252122.htm http://www.mzb.com.cn/html/Home/report/105836-1.htm http://www.pumch.cn/ References

Sichuan University

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Access to Mental Health Care Service for China’s Minority Patients and Foreign Patients with Limited Mandarin Proficiency (LMP) Wen Ren, Prof., PhD, Sichuan