Module 4 – Part 2 – Structural conditions

Looking at one of the central issues in healthcare provision for the new refugee population, which is the language barrier, it becomes apparent that most often not primarily cultural differences, but structural conditions contribute to communication challenges.

Example 1:

For instance, in Austria, physicians are not reimbursed by health insurance for the costs of consulting interpreters. Furthermore, also due to economic reasons the extra time they need for working with an interpreter is not compensated.

Example 2:

For example, in Austria, refugees living in refugee homes awaiting the decision on their asylum status only receive a small allowance. They cannot afford a ticket for a bus and might not be able to get a free ticket from the house management. Not having any transport options might have the effect that patients are not coming back for a control examination or do not go to the specialist you referred them to.

Simply put, if there is no translator available due to economic reasons or if there is no transportation available, this is not a cultural issue but a structural one. For this reason, it is often more important to reflect on the structural conditions rather than to focus solely on cultural differences (cf. Kleinman and Benson 2006). On the one hand, this refers to the health care system or economic conditions that you cannot influence; on the other hand, this also refers to the way you organize your medical practice, as the following example shows:

Case example (Binder-Fritz 2011, 135):

A young Muslim woman wearing a hijab/ headscarf and several layers of other veiling loose garments comes to a doctoral practice. She needs medical clearance for an educational institution. She is not willing to undress in front of the female doctor. However, the doctor is repeatedly insisting that the young woman strips to the waist, as she cannot conclude the medical examination without listening to heart and breathing sounds. Only very reluctantly, the young woman is willing to undress. The doctor is able to continue all the necessary examinations and the suspected diagnoses is a heart defect. She refers the young woman to a specialist who confirms the diagnosis and recommends surgery.


In summary, to overly consider cultural differences and respective shame barriers and to waive the heart examination would have been misguided in this case. In other cases, not insisting on taking off the cloths might make you oversee signs of physical abuse on a patient. Therefore, to help patients with a strong sense of shame and to guarantee an equal and equitable treatment it would help to minimally alter the structural conditions in your doctoral practice:  a sensible measure in this case could be a room divider/ screen that gives the patient some privacy. Furthermore, schedule a longer time window when a patient needs to undress (cf. Binder-Fritz 2011, 135).