Migrant worker language ability.

Most stakeholders agreed that language barriers were a problem, which meant that migrant workers received sub-optimal health services. Stakeholders acknowledged various language capabilities by migrant and refugee groups and length of stay in Malaysia, with newcomers experiencing greater difficulties compared to those who had resided in Malaysia for longer periods. Familiarity with the health system was attributed to length of stay and existing social networks. With the exception of new arrivals, the Rohingya were perceived to have greater system familiarity and better language ability than other groups such as the Chin, according to an IO participant:

"They are living in the cluster amongst the Chin population alone. [They are] unable to speak using a local language, never [have] mixed around with the other [communities]. So, even that when they come here, we [have] asked them: ‘Do you have any vaccination record?’ They probably [would] not understand what vaccination is about… [Most Rohingya] have been here for longer than the [Chin]; they are born here, [their] parents [were] probably also born here… they have been here for generations! They know the private clinics [and] they know where the public hospitals are.” [M-IO-4]

In Thailand, health staff perceived that migrant workers nowadays had higher competencies in Thai language compared to the past. Migrants who were fluent in Thai appeared to have better chances to secure well-paid jobs, or to become coordinators between Thai healthcare providers and migrant communities. There were various learning opportunities, from formal training of MHW/MHVs by health facilities, to informal education by temples, charitable organizations, or by self-learning:

“I know that there is a kind of school teaching Thai language in Samut Sakhon [one of the migrant populated provinces in Thailand]. If you do not know the language [Thai] before, you can start here, and you can study and work in the same time”[T-MHV-3]

Several stakeholders in Malaysia described differences in language ability by migrant worker nationality, with some even asserting that migrant workers had no issues communicating (M-CSO-3). Overall, Malay was considered an “easy” language to pick up in a short period:

“Some of the foreign workers ah, you must understand–the people who pick up Malay [language] very fast are–the Bangladeshis [and] Nepalese. I mean the Indonesians they [already do] speak Malay.” [M-HP-5]

“IND 1: Yeah, but you see, in our situation, normally it’s between 3 to 4 months they can start speaking [in the] local language.

IND 2: Basic lah. I think Malay is pretty easy to pick up.

IND 1: EXCEPT [the] MALAYSIANS! Some of the Malaysians don’t know how to speak after Merdeka [National Independence] for how many years? But [the] foreigners can do it!” [M-IND-1,2]

Two participants described migrant workers as having better language skills than Malaysian citizens. In Malaysia’s culturally and linguistically diverse domestic population, the expectation from these participants was that all citizens should be able to converse in Malay, especially if foreigners demonstrated this ability. One migrant participant suggested that the onus was on migrant workers to learn Malay:

“We don’t understand Bahasa [Malay language]. This is our problem. Whatever the employer or the doctor says… we migrant workers don’t understand!” [M-TU-2]

This participant implies that migrants should learn Malay in order to be understood by employers and doctors. Another doctor similarly inferred that migrants should be socially adaptable, and learn the native language:

“It’s about being able to adapt to where you are [as a migrant]. We can provide assistance but then, the demand for us to adapt to your cultural and your language ability, I guess that’s the problem?” [M-HP-10]

This doctor went on to question whether focussing on migrants who were more adaptable, compared to the minority who didn’t learn the language or local customs, would be fruitful:

“Well, it depends on their social adaptability… they can eat the local food, they speak very fluent Malay, but there are some who don't. So, I guess I can't generalise for all migrants as well; but… there (are) always those outliers. And so, the question is: ‘Do we actually focus on the outliers or those … general ones who are able to adapt?’ Which are mostly the majority.” [M-HP-10]

Migrant Health Workers who act as interpreters in Thai health facilities, perceived that interpreting services were very important to overcome language barriers. Some migrant workers did not know the exact meaning of Thai words, which led to miscommunication with Thai health professionals:

"When patients who could not speak went to see doctors without interpreters, some of them said they understood. In fact, they did not know how to explain the symptoms in Thai words. For example, they said they had fever [in Thai] but they had other symptoms.” [T-MHW-1]

Health workers’ language ability and patient communication skills.

Two participants remarked that health workers had low English proficiency and that migrants were usually asked if they or anyone they knew spoke Malay to communicate [M-IO-2, M-MW-3]. One trade union participant remarked that migrants didn’t have confidence in Malaysian doctors, linked to language barriers both ways:

“Mostly I get very negative comments about the Malaysian doctors. One, they have a very low confidence. And second is the language barriers. Some they cannot explain properly.” [M-TU-3]

Language barriers hindered the communication of complex medical terminology by health workers. One participant recalled an example of a migrant worker perceiving that they had a minor condition, compared to a serious procedure they had to undergo:

“There are certain terminologies that [the] doctor use: [they] are very difficult to understand… you don’t know what it actually means. Just to give you an example, this guy has got a lump and he has to go through the procedure. So, when the community worker accompanied him to the clinic, the doctor said: ‘No, no, no! Don’t worry, it’s just a small cut and we will just remove it!’ So, he came back and thought it was just a small cut … When the appointment day come, he’s actually admitted in the hospital… and… this was considered [a] surgery! So, he didn’t interpret it as ‘surgery’, he just told him [that] it’s a small cut, you just go taking a pill… You cannot take it at face value that the migrant workers understand everything that is explained by the doctor! Sometimes, they don’t even understand, that’s also good for you to get the second opinion.” [M-IO-2]

Migrant workers’ basic Malay language skills, combined with doctors sometimes not adequately explaining severity of conditions or procedures, meant that miscommunication occurred. Some participants inferred that doctors didn’t have empathy or patient communication skills to fully explain conditions to migrant workers prior to administering medication or treatment:

“I think the doctor also don’t understand our ‘bahasa’(language)… When we are sick the doctor does not explain what’s wrong with us. We don’t know what doctor is thinking… But he still gives medicine…” [M-TU-2] translated from Malay

It was difficult for health workers to communicate empathy with the language barrier according to this participant:

"In [the] government hospital, well, I think treatment wise, it’s not a problem, but you see–caring for a patient is just not [about] giving the pills. It’s also talking [to the patient], empathising and advising. How do you give these IF there is a language barrier? You can't do that. So, a nurse may come and say, 'okay, makan ini ya! [okay, eat this yeah].' That's all! Because she cannot do anything else! Otherwise, if it’s a local patient whom she can communicate [with], [the communication will be better e.g.,] 'mak cik, sudah masa ah, boleh makan ubat ini’. [Mam, it’s time to take your medicine.]" [M-HP-6]

It was easier to show good bedside manner and communication with local patients who spoke Malay. Some participants described doctors looking down on migrant workers because of their poor language abilities, and their impatience in treating migrants as a result:

“… because of the communication, and doctors maybe look down on the migrant workers, so they just give the Panadol lah! First of all, you cannot tell your problem in the language that the doctor understands. And then, the doctor doesn’t have the patience or [he] has low degree of humanitarian response. He won’t take it very seriously…” [M-CSO-1]

Migrants’ conditions may not be taken seriously, and prescription of unsuitable medication like Panadol was frequently described among participants. Medical errors were also described, although it is unclear whether these were always attributed to language barriers:

“I went to the clinic the other day because I had [a] fever. I told the doctor, ‘I had fever’. The doctor gave me an injection, after that I could not walk for 5 hours! After that, I went back to the clinic and confronted the doctor. He apologised and admitted he gave me the wrong medication!” [M-TU-2] translated from Malay

Employer perceptions of cultural differences with migrant workers.

An industry participant described different familiarity with modern medicine among migrant workers. Indian and the Nepalese workers brought their own medicines into Malaysia, as they had more exposure to modern treatments, while Indonesian workers were described as being more superstitious and reliant on traditional medicines (M-IND-1). Indian workers were not used to seeing doctors at home, instead relying on pharmacies where high dosage medicines were prescribed. It took a while for them to adjust to lower dosages administered by Malaysian health workers:

“But–that’s why–you see, certain workers–Indian workers: for the first year, normally–whatever treatment that we [have] done here–it’s not that efficient to them because they are used to taking high doses… That’s why, normally, Indian workers, after [the] second year they get used to the way Malaysians [are] being treated [medically].” [M-IND-1]

Indian workers often had these medicines confiscated at customs upon arrival in Malaysia.

Elsewhere, there might be high-handed ways of dealing with migrant workers by employers, which arose from the perhaps positive intentions to solve problems, according to a CSO participant. This participant described how employers responded with knee-jerk reactions to migrant workers behaviour that they didn’t understand, such as curfews in response to alcohol or drug addiction:

“The solutions have not always [been] ethical, [employers] really think: ‘How do I handle this drug and alcohol abuse problem? Oh [let’s do] curfew!’ Because [employers] don't have other options… the kind of issues these people face on a daily basis: there's no standard SOP for that. How do you handle one worker trying to run off with the other workers' wife? How do you handle someone abusing drugs… if you lose him … [those] men; your production is completely gone.! How do you handle it? … There's all these kinds of issues that these people have to deal with on a daily basis and mental health issues [as well]… [Employers would] just receive a group of workers [that] they know literally nothing about beyond their basic bio-data; and then they live in community, which is also the difference with palm [sector]. So, it’s very complicated.” [M-CSO-5]

This participant went on to infer that beyond health workers, it was important for human resource staff and middle managers overseeing migrants they hired, to understand cultural differences as well:

“Sometimes there's no easy solutions for company staff; [as well as] trying to deal with a very diverse group of people [of] different nationalities. Different cultural clashes, [Or they have different] education levels–it’s not easy! … I think we have to keep that [question] in mind:… People that are dealing with migrant workers, even at the company level–not even at the hospitals and medical clinic level, even just HR person, the middle manager: ‘Do they know how to really deal with these cultural issues too?’” [M-CSO-5]

A policy stakeholder similarly felt that cultural differences with migrant workers were a major barrier to understanding with employers and locals more widely. This stakeholder felt that cultural education for migrant workers, before they came to Malaysia, could potentially remedy misunderstandings. This stakeholder compared migrants coming into Malaysia before as being more trained in cultural know-how, to now whereby more incoming migrants and lack of cultural understanding was a concern:

“From the country of origin, they need to be introduced to cultural knowledge and how to adapt. It has worked well in the past. But somehow when the [high] volume [of migrant workers] gets in, you don't really see that now! I remember those days, Bangladeshis [would] come, they are very polite. Those who have high qualification, the character is good, they plan well, they learn Malay very fast [and] they work with locals–[the] Indonesians as well.

But [when] so many come, the volume is there; then you see a bit of differences [in these qualities]. It is hard, if we don't control [immigration], we might have the same feeling of [the] British [people] when they talk about Brexit. That might happen! The sentiment! IF you know, they came in, filling [jobs at] the workplace. Somehow, they are not culturally accepted … So, it will create more hate and also AFFECTS the society.” [M-POL-2]

This participant implied that migrants being absorbed into the labour market might generate anti-immigration sentiment among citizens. They went on to describe how Malaysians were accepting of migrant workers, but that cultural misunderstandings posed a threat to societal harmony:

“We are very accepting [towards] [migrant workers]. Actually, on the cross-cultural issue…. as a Malaysian we are already dynamic. We have high tolerance on other races, we don’t talk about racism or what not. We are Malaysians but somehow when they [migrant workers] come in, we have another set of cross-cultural issues. They have to respect this society of Malaysia rather than looking at us as different races… This cultural issue [is] very, very serious to me.” [M-POL-2]

The implication was that migrants should respect Malaysian culture and adapt accordingly.

Informed consent and medical errors.

Several participants noted that language barriers delayed healthcare seeking among migrants, who might present at clinics with late stage serious conditions. Worryingly, language barriers could lead to a lack of informed consent with migrant patients even for serious procedures when they did seek care, as described by this participant:

“My friend from Ipoh worked in a plastic factory. He had an accident, and cut his finger. He told his employer: ‘I don’t want to amputate my finger!’ The doctor did not understand [or] maybe the employer told him differently. The worker could not understand the Malay language. So, the doctor amputated! [Below elbow amputation].” [M-TU-2] translated from Malay

This participant went on to question why below elbow amputation procedure was done when the patient refused and when the injury was on the finger, indicating poor communication from the health provider. As a result of medical errors, perceptions that doctors didn’t take their conditions seriously, and sometimes lack of informed consent, migrant workers might develop fear and mistrust of health workers. A public-sector doctor suggested that the threat of legal action was an incentive to ensure patient consent was taken (M-HP-4). Among doctors overall, adhering to professional standards of care was perceived to be important. Migrant CSOs or TU’s disagreed in some cases.

Mental health assessments.

Language barriers were amplified when doctors had to make more nuanced assessments of a migrant patient’s mental health condition. While the MOH Malaysia had developed a detailed mental health screening tool, this was considered impractical to administer with migrant patients because of the language barrier (M-HP-5). Screening for psychiatric illnesses is conducted as part of the mandatory medical screening process for incoming documented migrant workers, which was implemented by FOMEMA, a company appointed by the government to conduct foreign worker’s medical screening. In Malaysia, having a psychiatric illness is a deportable condition. But, it was unclear how FOMEMA panel doctors screen for mental health disorders. This doctor went on to describe a simplified, visual form of mental health assessment for migrant workers used for this purpose:

“HP-6: So, they [doctors]'simplify' it to get a basic mental assessment.

HP-7: Well… things are quite good actually. So far, it's okay… It's compulsory. So, everybody's doing it. So, you simply–basically are looking at the behaviour, his dressing, the way he talks.

HP-6: The manner.

HP-7: You know the manner, these kinds of things, you know; [but] no detail [or] that history on his friends and families.” [M-HP-6,7]

Some doctors perceived that diagnosis of mental health conditions via a visual inspection of a patient’s manner and condition was accurate enough, rather than administering a validated screening tool in the appropriate language. One doctor went on to explain that panel doctors’ remuneration by FOMEMA for conducting migrant worker screenings were very low and had not been revised for two decades, which incentivised doctors against conducting a lengthy, time consuming mental health screening:

“Secondly, this FOMEMA… while we are agreeable to do anything the government wants We are also–not been treated [justly]. A 60 Ringgit [service fee] has been given for the last 20 years! So, if you give me a 60 Ringgit [fee], I mean let's be honest. I will do a good job but if you asked me to spend 40 minutes on a mental [health] test, I won't do [it]! [M-HP-5]

According to some doctors, it was easy to infer that migrant workers had mental health conditions, when they often arrived in Malaysia with debt or had made sacrifices to migrate:

“…He will say, 'I sold my cow when I came [to Malaysia]; I sold my buffalo and came [to Malaysia].' So, all these are natural [mental health] problems.” [M-HP-5]

It was considered unfair that doctors had to make lengthy assessments without adequate compensation from FOMEMA. In these cases, using an interpreter to infer whether migrants were symptomatic for mental health disorders, would presumably take more time than the visual assessment.

Migrants were concerned about privacy and possibly stigma when disclosing mental health issues, which meant that those attending a mental health clinic wanted interpreters from outside of their home community. As one service provider explained:

“[That] is such an important thing (because) ‘word of mouth’ [and] the gossip, which passes between [the community]… is something which is very toxic and very hard for them to get through. For example, if we have a Pakistani Ahmadiyya patient that comes in, there are cases where they have said: ‘We would prefer if the person who was translating or the person who was providing us with the service IS NOT from the Ahmadiyya community! But it could be someone who is a Pakistani Christian’… it’s okay to talk then.” [M-CSO-10]

Beyond gender, religious and ethnic sensitivities were considered when choosing interpreters. This participant went on to describe difficulties where equivalent terms did not exist in the migrant’s native language for mental health conditions:

“…It’s also very difficult [to get the terminologies right]. For example, how do you translate ‘schizophrenia’ into the Burmese language? Or even to a Rohingya person? That word doesn't exist [in their dictionary]! So, even [the term] ‘stress’ or ‘anxiety’; it’s also about [the interpreter] having to understand the meaning of it: the signs and symptoms… behind it [and] to be able to translate it to someone else; and not just interpret it as [it is].” [M-CSO-10]

This provider had created a glossary of mental health terms for various migrant languages, and system of community health workers to mitigate some of the difficulties in conducting mental health assessments with migrants.

Health worker strategies.

Doctors had several ways of mitigating language barriers with migrant workers, ranging from use of Google translate to sign language or gestures to try and bridge the language gap:

“Of course it’s difficult if they don’t bring someone to help communicate. But then we have Google translate. We just use Google translate and it’s somehow working.” [M-HP-4] translated partially from Malay

Just one doctor in Malaysia mentioned learning migrant languages in order to communicate (MD-1). While in Thailand, short courses for health workers were provided by Provincial Health Office, MOPH, teaching basic communication in Burmese related to health issues and cultural differences. However, there were concerns about time constraints to attend courses. Burmese accents were difficult for doctors to pick up because of different accents among ethnic groups in Myanmar:

“Provincial Health Office supported Burmese training course in the weekend for health personnel who were interested…To take patient history, I tried to read Burmese words, but patients [are] still confused because of incorrect accents” [T-HP-18]

In Malaysia, Doctors usually encouraged migrant patients to bring an English or Malay speaking colleague, or Malaysian partners in the case of some migrant women, along to help interpret during consultations (M-HP-8, M-HP-1). However, in public hospital outpatient departments, time constraints meant that doctors would rather resort to hand gestures rather than request friends to act as informal interpreters:

“Unless it’s in a government hospital, [there’s a] line up to 100 patients, you know, I don't have time to call 3 fellas [fellows] to come and do your interview! I already understand you, from what you are telling me, you know, maybe we can even say, you know. Yeah, [it's] cough [or] running nose.” [M-HP-5] [Participant demonstrates hand gestures]

Doctors in inpatient and ICU settings were more likely to search for colleagues or friends to interpret for a patient’s history, and resort to treating symptomatically until then. Among informants in Thailand, there was much less confidence expressed in health workers’ ability to overcome language barriers without interpreters, via gestures or otherwise. If there were no interpreters in health facilities at that time, Thai health workers similarly resorted to asking patients to find someone who could help interpret nearby:

"[When patients came to health centre without interpreters], I would ask them to find people nearby who could speak Thai. I would not prescribe drugs [without receiving information] because it was harmful to patients. Sometimes, we knew that they had stomach ache and we could guess [diagnosis] from surrounding contexts. However, we would like to know the exact diagnosis so we usually asked for migrant workers who could speak Thai to interpret coming with patients.’ [T-HP-8]

Employers strategies.

Migrant workers were deliberately not given hazardous jobs in plantations due to language barriers inhibiting their understanding of occupational risks, according to this industry participant:

“[Occupational Safety and Health (OSH) training material is given in] pictorial form and also during the [occupational safety and health] training we (will do) demonstration [on] what they can or cannot do. The bottom line is: usually for–hazardous jobs… we (won’t put them there)–mainly our foreigners/[workers] are focusing on … harvesting and some other general work as well." [M-IND-2]

Employers also described peer liaisons with Malay language ability on worksites, alongside the Estate Hospital Assistants (EHA) which are mandated by Malaysian legislation to be present on each plantation:

"So, in terms of language, of course, they have to use some simple language, and they don't get [interpreters]–because there are three or four different type of languages; you can't bring an interpreter for each and (all) but they have [a] person who comes and explains to them: by showing equipment and signs and all that. But they do have regular [training] and then–you have this Estate Hospital Assistant [EHA] in this big plantation, who [would] also give training to their workers regularly; on fire safety [and] on chemical exposure: ‘What happens if you have a chemical splashed on your face? What do you do?‴ [M-HP-7]

The Workers’ Minimum Standards of Housing and Amenities Act 1990 (Act 446) states that plantation owners have the duty to provide workers and their dependents with medical attendance, care and treatment at the estate hospital, group estate hospital or estate clinic. EHAs were an essential link between migrant plantation workers and service access, but it is unclear if any training was offered to EHAs on the cultural differences between migrant workers on care-seeking or factors that would affect health service use.

Quality of training delivered in native languages on plantations was variable/unknown according to a CSO participant:

“Sometimes for the trainings, what they do is [that] they will do it by batch of workers. So, they will do like the Nepali batch first. Then worker who's been there longer would be the interpreter for the others. That is quite common that they that they ensure that people understand that way. But what is the quality of the interpretation given by the head worker who has been there the longest? I don't know.”[M-CSO-5]

This participant went on to describe cultural differences in perceptions of health and safety among migrants, which put them more at risk of accidents:

“We have to all go forward together and there needs to be greater awareness about health and safety … It's like … we have someone who came to try to fix some lights here in our office. The guy doesn't even turn the light off before starting–he is getting a zap! [But he was like]: ‘Ah! Doesn't matter!’ It’s this mentality.” [M-CSO-5]

Companies did not push OSH training or a strong safety culture as much as they should because workers became aggressive or demotivated in response, according to this participant. A policy stakeholder described how the government OSH agency supported training, recruiting local ethnic Chinese and Indian Malaysians as interpreters, who may then become OSH trainers for migrants from those countries:

“From our side, we get the trainer who can speak their language. Like currently there (are) a lot of Chinese [migrants] coming in; so, we [do] use local Chinese [interpreter] to match that [demand]. And we introduced the local Chinese to them, then if it works well, then we can use him as a trainer–and he is a registered trainer as well. (whereas for) Indians, we use [the] local Indians [as translators], test it out whether the dialects fit [the audience]–then we [will] carry on. Otherwise we can allow them [clients with Indian foreign nationals] to bring interpreter. Then we [will] check continuously–check on the delivery [standards].” [M-POL-2]

This participant went on to suggest that Embassies of sending countries like Myanmar should be consulted, to locate interpreters for OSH training.

Informal interpreter systems at CSO clinics.

Informal interpreter systems consisted of community members who may be refugees, asylum-seekers or migrant workers informally acting as interpreters in CSO clinics. One participant described improvements that needed to be made, broadly around the professionalisation of informal interpreters. Interpreters needed training on ethics and patient consent:

“We do [have] code of conducts, we do [have] ethics, and we talk about all confidentiality, non-disclosure, consent–[which] is a huge thing for us. So, we need to make sure everything is [clear and that] they understand why we need to get consent; how to share information; what [kind of] information can be shared. Even amongst the interpreters. So, for example, let's say the patient disclosed this thing to the doctor in this room: ‘You shouldn't share the information with the other interpreter in the next room when you go out for lunch!’”[M-IO-4]

This participant went on to discuss the challenge of interpreters getting used to regular working hours and the general need for training on professionalism and work culture:

“This is something new for them as well. They have not been in [an environment and] working formally. So, this is something that we need ‘training’ [on]; we need to also get them used to it: ‘that you need to “clock-in” in this hour.’” [M-IO-4]

Furthermore, interpreters had to be familiar and keep up to date with medical terminology and conditions. In CSO clinics with informal interpreter systems, continuing training consisted of talks by specialists.

In Thailand, formal interpreters or MHWs usually worked in health facilities and received formal training. Informal interpreters or MHVs worked in communities. MHVs also received training by healthcare staff, but this training was focussed on basic health education with less emphasis on interpreting skills or healthcare and professional competencies. However, some migrant interpreters expressed interest in learning skills beyond their interpreter role, such as preventive care, basic life support and first aid:

"Sometimes they [healthcare staff] performed CPR, I would like to learn and know about it. In the emergency situation, it was unpredictable what we would confront, so I would like to help others." [T-MHW-7]

Although, some MHWs were eager to acquire more clinical knowledge and work further beyond their interpreter role, some health workers opined that MHWs’ roles should be limited only to interpreting functions:

"The point is that you cannot advise [patients] because that is the role of doctors. You should not tell patients that they had hypertension 100%, so you could do only measuring blood pressure and interpretation." [T-HP-3]

In Malaysia, two main problems were identified with hiring asylum seekers or refugees as informal interpreters: the inability of CSOs or IOs to formally hire them given Malaysia’s legislation prohibiting employment among asylum seekers and refugees, and; what was perceived to be conflict of interest among IOs or UN agencies, whereby informal interpreters were also beneficiaries of their organisations (M-IO-4). Difficulties hiring interpreters present another barrier to improving cultural competency. While formal interpreters can be officially hired by the MOPH in Thailand, there is no training for informal interpreters or other supporting systems for professionalism.

“Opening the floodgates” and domestic priorities.

However, participants touched on real and perceived resource constraints to improving cultural competency. One participant alluded to the perception that system improvements for migrants in the form of interpreters would encourage further use of an already stretched health system:

"You know, whether they [interpreters] get payment or whatnot; and of course, the other people [will say]: ‘Having this, is just–just not only going to attract them? Oh, now not only they can tap into the HEALTHCARE SYSTEM! We allow them [to have access to] TRANSLATOR! They are (going to get better [services].’ You know, ‘What are you giving them now?‴ [M-POL-1]

This participant described interpreters as a gateway to further concessions or systems improvements for migrants, which the general population would disagree with. One service provider described how domestic healthcare challenges meant that policies on refugees or migrants had less priority:

“At the current moment, there is not a huge area of discussion for policy [on] refugees and asylum seekers because we can't even work on our own health issues [in the country]. It’s a bit difficult to bridge the topic itself, but we [are] (trying) to get involved in a larger scale with our partners/working groups.” [M-CSO-10]

Availability of guidelines on cultural competency for health workers.

In Malaysia, participants did not have MOH guidelines on cultural competency to refer to. In contrast, Thailand’s MOPH has a medical terminology guide which is translated to the main migrant languages [46]:

“It was a book like this [bilingua dictionary]. Sometimes it printed in book while sometimes it was in one-page paper. [When I would like to use it], I opened it to see common words like stomachache, vomit or fever. The common used words were provided in this book.” [T-HP-18]

Generally, doctor-patient manner and cultural competency was perceived to be something doctors learnt on the job, when it was not formally included in medical school curriculums:

“During my time I don't think they have this kind of [cultural competency] programmes. I don't think we were taught that much in medical ethics as well–medical law or about all the social behavioural sciences. We were very focused on physical health, not even mental health–I guess, in Malaysia, it’s a big taboo [to talk about] mental health. We haven't gone past that yet as well. That’s also a big hurdle for us but in terms of this soft skills and cultural competency, I guess it comes with experience.” [M-HP-10]

Cultural competency was also needed for mental health according to this participant, which remained a taboo subject in Malaysia. Learning on the job and coping with existing language barriers and cultural differences with migrant workers was commonly reported by health workers in this study.