Patient Education and Counseling 46 (2002) 253±259

The future of intercultural mediation in Belgium

Vera Nierkensa,*, Anja Krumeichb, Ri de Ridderc, Martien van Dongend
a
Department of Social Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 15,
1105 AZ Amsterdam, The Netherlands
b
Department of Health Care Ethics, University of Maastricht, Maastricht, The Netherlands
c
General Practitioner, Gent, The Netherlands
d
Department of Epidemiology, University of Maastricht, Maastricht, The Netherlands
Received 26 March 1999; received in revised form 12 March 2001; accepted 6 May 2001

Abstract

Intercultural mediation was developed to solve problems between western (Belgian) health professionals and Turkish, Moroccan and
Italian clients. The need for intercultural mediation in Belgium Health Care was measured by asking intercultural mediators to complete a
questionnaire about situations in which language, culture, social-economic and personal circumstances cause dif®culties. Results show that
the profession `intercultural mediator' continues to be important in improving the quality and accessibility of the Belgian health care for
ethnic minorities. Even if clients speak Flemish ¯uently, there are still dif®culties between health professional and client caused by culture,
social-economic and personal circumstances. # 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Intercultural mediation; Health care; Counselling; Ethnic minorities

1. Introduction Mediation in Health Care'' promotes the interculturalisation

of health care in Flanders.2 If the project improves the
In 1991, 4.5% of the Flemish population (259,601 residents) quality of health care and if the need for intercultural
in Belgium had no Belgian passport. In the ``Brussels capital mediation continues, the project will get a permanent struc-
district'' the percentage of residents without Belgian pass- ture. In addition to the qualitative effect evaluation of
port was even higher; 28.5% of the district's population Verrept [3], a quantitative enquiry evaluating the need for
(271,903) did not have any. About 45% of the people without the continuation of the project took place in 1995. In this
a Belgian passport are of Turkish, Moroccan or Italian article, the results of this evaluation will be described. It
nationality. Besides, there are numerous people who do shows that ICMs have contributed considerably to the
have Belgian nationality but who are of foreign descent [1]. solution of problems in health care, but that they remain
Research shows that the accessibility of Belgian health indispensable even after 5 years of mediation and advocacy.
services and their quality is lower for Turkish, Moroccans
and Italians than for Belgians.1 To improve the accessibility
and quality of health care the Flemish Ethnic Minorities and 2. Problems in multicultural health care
Health Care Centre (EMHC), started the project ``Intercul-
tural Mediation in Health Care'' in 1991. By training inter- International literature mentions language and culture as
cultural mediators (ICMs) of Turkish, Moroccan and Italian important obstacles in the provision of adequate health care.
origin they try to solve the problems minorities encounter Communication between health care staff and its clients, is
while seeking health care [2]. the basis for effective diagnose and treatment and lack of
The Flemish federal part of the Belgian government, who adequate communication is a major explanation for the poor
®nances the project, hopes that the project ``Intercultural access and the low quality of health care for members of
ethnic minorities [4,5]. Many migrant clients only speak
*
Corresponding author. Tel.: ‡31-20-566-7436;
fax: ‡31-20-697-2316.
2
E-mail address: v.nierkens@amc.uva.nl (V. Nierkens). This project is aimed at the Flemish situation in health care. Although
1
The quality and accessibility of health services can be bad for other similar problems occur in Wallone (the French speaking part of Belgium),
minorities too, but about these groups no information has been sought. this has not been the object of the study discussed in this paper.

0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 7 3 8 - 3 9 9 1 ( 0 1 ) 0 0 1 6 1 - 6
254 V. Nierkens et al. / Patient Education and Counseling 46 (2002) 253±259

their native language [4±8], while the English speaking mere translation. Le¯ey and Bestman [29] describe a project
family members who often accompany non-English speak- in mental health care in which practitioners of a speci®c
ing clients are believed to translate information from health ethnicity are trained to apply their expertise to clients of the
professionals wrongly [9]. same ethnic background. In this project, both clients and
One of the reasons for such translation problems may be clinicians were trained to deal with each other adequately. In
that cultural differences between health professional and Canada, ``culture brokers'' educate clients about the orga-
patient also affect proper communication in health care nisation and functioning of the health care structure and
settings [10±12]. In their research on Indo-Chinese clients, advocate for the client's position [28,29]. In Great Britain,
Hoang and Erickson [9] describe how cultural differences ``health advocates'' translate during consults, but also edu-
form ``barriers'' which seriously impair the health providers cate clients and clinicians and advocate for clients' rights
as well as the patient's ability to understand each other. [30±34].
They mention clients who, for example, did not want to eat
speci®c food because they believed this food caused an
imbalance which made them sick [9]. Numerous, more 3. Problems in multicultural health care;
recent, studies into multicultural health care settings, come the case of Flanders
across similar problems resulting from different perceptions
of illness and health [4,11,13,14]. Medical anthropologists A preliminary investigation, entailing participant obser-
emphasised differences in personal and cultural explanatory vation during consults and home visits with ICMs, analysis
models regarding illness, health and anatomy of the human of diaries of ICMsÐduring their training ICMs were sup-
body. These models determine what people expect from posed to keep a diaryÐand of earlier studies concerning the
health care and how they evaluate the care received Belgian situation shows that Belgian migrants experience
[10,12,15±17]. When these models differ too much from dif®culties that are similar to those discussed above [35,36].3
the health care professionals' views communication will Many of them do not speak the Dutch language [21,37±41].
become problematic. Eylenbosch and Peeters [37] estimate that migrant clients
Non-verbal communication patterns also differ from usually understand one third of the information provided
culture to culture as well, adding to the already dif®cult during health care encounters whereas Belgians understand
communication. Indo-Chinese clients for instance ®nd it two third of this information.
impolite for a health professional to pat a client's head [9]. Cultural differences interfere with successful communi-
However, although cultural differences can lead to inter- cation in Belgium as well. One of the mediators of the
action problems, health professionals, on the other hand, Flemish project for instance, mentioned a client who did not
often mistakenly interpret their client's behaviour as want to give blood because she assumed that her body could
``cultural'', using culture as an excuse for failing commu- not replace the four ``bottles'' of blood that she supposed the
nication [18,20,21]. Differences in educational level may doctor wanted to take from her. Rijkschroeff and The [40]
in¯uence adequate communication as well. Literature concluded that health professionals often consider a client's
shows that clients with a low educational level frequently unexpected behaviour a result of his or her cultural back-
encounter communication problems [19,25]. The educa- ground. Thus, these professionals blame the client's cultural
tional level of people who migrated to Belgium and other background and deny responsibility for consequent decrease
European countries is often quite low and communication in the quality of communication, diagnosis and treatment
problems can be expected [22±24]. Many health profes- [21]. Stagnating communication often resulted in health
sionals fail to take this into consideration and as a result professionals missing important information to diagnose
their information is inappropriate [25,26]. and treat adequately. ICMs came up with similar experi-
Besides differences in language, culture, and level of ences.
education, social factors in¯uence the quality of interaction. Furthermore, the average level of education of migrants
As a result of differences in social class [27] and gender [6] remains below the general average educational level in
for instance the health professional often tends to dominate Belgium [42,43] while health professionals often fail to
the encounter, rendering interaction unequal and one-sided. adjust their information to the client's education level.
Moreover, many clients lack ®nancial means for high quality Moreover, few migrants appear to be familiar with organisa-
health care [7,8,29]. tion and structure of the Belgian health care system [33].
Solving problems due to an increasingly multicultural During the study, it was for instance observed that ICMs had
clientele in health care require new initiatives and in many to explain that is was important to visit the consultation
countries projects have been developed to tackle these bureau (child health clinic) because that was where children
problems. Westermeijer [5] and Faust and Drickey [28] were vaccinated.
describe programmes in the US in which interpreters with
the same ethnic background translate and explain informa-
tion for migrant clients. Besides these ``translator projects'', 3
Because of the comparability of the two countries, literature on the
projects have been implemented which involve more than Dutch situation is included in the study.
 V. Nierkens et al. / Patient Education and Counseling 46 (2002) 253±259 255

Finally, clients often lack money for adequate care. A pair The questionnaire consisted of 24 descriptions of poten-
of glasses for instance, or a hearing aid for a child, are often tially dif®cult situations (Fig. 1). The ICMs had to indicate
beyond clients' ®nancial means according to ICMs. To for each of these situations whether it had made intervention
communication problems due to cultural and social-eco- necessary during a particular mediation and, if so, how
nomic factors personal problems such as a bad relationship severe the problem was, or could have become had he or
with family-members were added. she not been present. They had to estimate the degree of
Belgian solutions to problems of multi-ethnicity are dif®culty on a ®ve-point scale, ranging from ``not dif®cult
similar to those adopted in other countries. In Belgium, at all'', to ``very dif®cult''. The questionnaire also included
ICMs tackle the problems. They act as interpreter between questions about background characteristics from client,
health professional and client and they alternately adjust health professional and setting.
their translation to the frame of reference of health profes- The questionnaire was checked for comprehensibility,
sional or client. They educate clients about the Belgian completeness (face validity), reliability and validity. To test
health care services and they explicate (describe) medical the comprehensibility and completeness, ICMs were invited
terms and give other sorts of health education. They also to comment on a provisional questionnaire. Consequently,
inform health practitioners about their clients' cultural some of the questions were rephrased, but there was no need
habits and ideas [44]. Thus, health professionals' under- for additional questions. The reliability-analyses shows
standing of their clients' behaviour increases, while clients alpha's from 0.69 to 0.93, rendering reliability suf®cient.
develop more realistic expectations of (the outcomes of) It was dif®cult to assess the validity.
treatment. The results were analysed with the statistical package
Also important is the ICMs' task to advocate the rights of SPSS 6.1W. Dif®cult situations that occurred most fre-
their clients. Whenever health professionals inform clients quently were analysed. It was presumed that dif®culties
inadequately, or treat them insuf®ciently or disrespectfully, that were not mentioned would not cause problems. The
ICMs request explanation [44]. ®rst analysis consisted of a frequency table of the selected
Although the ICMs are believed to have a positive input items and concerned the frequency of occurrence as well
on health care delivery in Flanders, the need for a systematic as the degree of dif®culty. Second, the (average) number
evaluation was felt. Because a qualitative evaluation had of (very) dif®cult situations within one mediation was cal-
already been carried out this time a more quantitative culated. The third analysis consisted of counting the
methodology was preferred. number of ICMs who reported a speci®c situation. With
the Kruskal±Wallis test was assessed the signi®cance of
the impact of the length of the periodÐduring which a
4. Methodology client resided in BelgiumÐon the number and the severity
of the problems.
4.1. The questionnaire

To estimate to what extent the services of an intermediator 4.2. Response and sample
remain necessary a questionnaire about situations in which
language, culture, social-economic and personal circum- A total of 171 of the 236 questionnaires were returned.
stances cause dif®culties was developed. Some 59 out of Two were unusable, which caused a response rate of 70.8%.
60 ICMs were requested to ®ll in this questionnaire for four Reasons for non-response were checked. They did not affect
mediations selected at random. The items of the question- the results.
naire are presented in Fig. 1. The reason to approach ICMs The sample consisted of 55% Turkish, 22% Berber, 17%
for this study was that earlier studies had focused on the Arabic and 2% Italian clients. Eighty percent were female.
physicians' perspectives. It was assumed that the mediator's Most clients were between 20 and 45 years old. Thirty-six
point of view might differ from that of the physicians and percent of the clients had come to Belgium more than 15
that mediator's are in a better position to interpret and years ago, 20% had arrived 4±15 years ago and 24% had
understand the problems of a client whose cultural back- lived in Belgium 1±4 years, 7% was born in Belgium. Most
ground they share. clients had a low education level: 70% had not reached
Because the mediators worked in a variety of health care secondary school level.
settings we got an overview of the dif®culties in all these The composition of ethnic groups in the sample differs
settings. Most of the mediators (43%) worked in ``Child and from the composition of the ethnic population of Flanders
Family'', the healthcare organisation for children from 0 to 4 and Brussel in general. If the Moroccan, Turkish and Italian
years old. Thirty percent worked in a hospital. Other orga- were seen 100%, the percentages would come to 49.5, 26.3
nisations working with mediators were: `Medical School and 24.2%, respectively in Flanders. The incomparable
Supervision', the health care organisation for children from distribution is caused by the distribution of ICMs, because
4 to 12 years old, GP's, centres for mental health care and the percentages of the ICMs are comparable with the ethnic
organisations for `social health care'. distribution of the clients.
256 V. Nierkens et al. / Patient Education and Counseling 46 (2002) 253±259

Fig. 1. Items of the questionnaire.

5. Results About 53% of the consults would have been (very)

dif®cult had the ICM been absent. Results show that,
In general one can conclude that, if it had not been for the although only 19% of the clients spoke Flemish suf®ciently
ICMs' mediation, many clients would have encountered to be understandable, in only 15% of the consults language
problems in their dealings with Belgium health care. Dif®- was the sole source of problems. In 70% of the measured
cult situations appeared to occur quite frequently. Language, consults clients would still have experienced problems even
cultural barriers, and social-economic and personal circum- if they had been perfectly ¯uent in Flemish. Cultural barriers
stances came up often. and social-economic and personal circumstances of clients
 V. Nierkens et al. / Patient Education and Counseling 46 (2002) 253±259 257

accounted for most of the ICM interventions. The ICMs years of mediation during which ICMs in Flanders informed
indicated that their mediation was required in 15% of the health professionals about their migrant clients' culture,
consults because of disagreement about treatment. This migrant clients still experience problems concerning quality
disagreement resulted from different perceptions of illness and accessibility of the Belgium health care. They still rely
and, consequently, of different expectations concerning on the mediation of trained ICMs. How long migrants live
treatment. in Belgium did not affect the number of problems they
The relationship between client and clinician also needed experience. On the contrary, the frequency of some problems
intervention. A total of 11% of the health professionals increases with the length of residence in Belgium. Further-
wrongly interpreted their client's behaviour as ``typically more, even if language problems decrease in the future
cultural'', whereas 14% of the clinicians gave insuf®cient (as some may expect), an ICMs' intervention will remain
information. Finally, interventions linked to social-economic indispensable in most situations. Other studies seem to
and personal circumstances (like, for instance, a bad rela- con®rm the ®ndings of this study. They indicate that mig-
tionship with the family), bad living conditions and too rants still encounter a variety of problems during medical
little information about clients for health professionals, consultations [6±11,24].
ICMs were deemed necessary in respectively 11, 13 and A reason not just to continue but even to extend the ICM
23% of the cases. project is that our study implies that migrant clients of health
Moreover, the analyses showed that problems arose inde- care centres which lack the services of ICMs encounter
pendently of region or type of health care setting. Results of considerably more problems with these centres than with
the survey show that all problems mentioned in the literature health care centres who do pro®t from the mediations of the
did indeed occur on a frequent basis. The number of years ICMs. Moreover, health professionals who did work with
during which a migrant lived in Belgium interfered with ICMs may still not know all there is to know about their
some of the variables. As could be expected language clients' speci®c background, but during the years they may
problems decreased when clients lived in Belgium for a have learned a thing or two through their ICMs. Clients of
longer period (w2 ˆ 14:0; P ˆ 0:01). However, the longer health care services working without ICMs have not had any
clients lived in Belgium the more often they disagreed with chance to get education from ICMs either. Thus, even if
the proposed treatment (w2 ˆ 12:7; P ˆ 0:01). Furthermore, ICMs would become super¯uous at the health care settings
clients living in Belgium for 1±4 years more often had in which they worked so far, which as shown above, they
problems with other family members (w2 ˆ 10:2; P ˆ would not, many settings remain in which the services may
0:04). There were no other signi®cant differences related improve with the introduction of intercultural mediation. For
to the duration of residence. However, clients appeared to this reason, we deem it important to extend the project to
experience fewer problems with advocacy of their rights health care settings which have so far lacked the assistance
after having lived in Belgium for a longer time. Finally, it of mediators. This concerns institutes in both the French as
was remarkable that clients relatively often experienced well as the Flemish speaking part of Belgium. Additionally,
problematic situations when ICMs did not (or could not) since ``new'' minorities continue to arrive in Belgium, ICMs
assess the length of client's residence. of a larger variety of backgrounds will be required. Increas-
ing amounts of people ¯y from their country because of war.
National and international experience shows that it is highly
likely that they will encounter problems similar to those
6. Discussion of the minorities discussed in this article. ICMs of the same
background as the newly arriving refugees can improve
This study is an attempt to quantify the problems clients accessibility and quality of the health care services for these
and intercultural mediators encounter in a variety of health groups too.
care settings. The study showed that mediators still encoun- In short, considering the outcome of the project evalua-
ter many problems when acting on behalf of their clients. tion, it can be concluded that, instead of ending the ICM
The mediators indicated that they solved many of these project in Belgium, it is wise to extend the project to health
problems. This implies that their involvement is effective. care settings in French and Flemish Belgium that so far
However, although qualitative data [3] and short periods of have lacked the services of ICMs. Training of additional
observation seem to con®rm the mediators' opinion con- ICMs with other ethnic backgrounds is advisable as well.
cerning their effectiveness, we only included the mediators' As discussed in the introduction to this article, national and
experiences in our study. Therefore, an additional effect international literature shows that other countries experience
evaluation in which effect can be measured at different similar problems and seek similar solutions. There is no
moments in time and in which different health care settings reason to expect that developments in their countries will
can be compared, is desirable [3]. deviate from those in Belgium and that their attempts will
Results of the survey in this article do show, however, that become dispensable in the near future. On the contrary if the
the profession of ``intercultural mediator'' is and will remain situation in Belgium is representative, world-wide more
important for the quality of health care for migrants. After 5 ICMs will be needed in the near future.
258 V. Nierkens et al. / Patient Education and Counseling 46 (2002) 253±259

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