Good morning, everyone. Welcome to the last part of our Periscope module. I am Eloisa Franchi. A physician and researcher in public health. This training is titled equitable engagement in humanitarian contexts, and we'll focus on physician-patient communication in humanitarian settings, referring to the specific case of COVID-19 vaccination. Our training will proceed along three steps. First, we will take a look at what the existing literature say about physician-patient communication with a particular focus on marginalized population and humanitarian settings. We will then take a look at some ethnographic insight that will help us better contextualize this literature, and finally, we will draw from the ethnography some suggestion to improve communication and does better promote COVID-19 vaccination in on the move population. Let's start. Patient-physician communication encompasses all formal communication, verbal, non-verbal, written, etc., that occurs between patient and their physician. The medical examination we begin with the time of taking medical history is the moment when the various power relation that ran through the doctor-patient encounter become evident. The encounters between patient and doctor can be considered a micro-political situation that reflects and support broader social relations and conflicts. Communicate with patient is always a thorny issue, and is often one of the biggest challenge for clinician, often inadequately prepared during the course of the studies. In fact, most training programs after medical school do not include communication skills in their curricular and are often not even included in the formation of health humanitarian worker. In general, patient-physician communication has been shown to be linked to patient satisfaction, compliance, and health outcomes. In multicultural environment and with minority population, the issue of communication may play even a larger role because of linguistic and contextual barriers that preclude effective provider-patient communication. While these factors can certainly be important, but don't decide during critical intervention in the field, they become crucial when it comes to talking about chronic condition, prevention, and complex issues such as vaccination. The literature has identified many factors that interfere with proper physician-patient communication in humanitarian settings related to patient, to clinician, and to the healthcare system in which they are agents. These factors include language proficiency, health and digital literacy, cultural competency, the time dedicated to the visit, communication skills, and unconscious bias. The context of the COVID-19 pandemic was emblematic of these dynamics. A little bit of ethnography can help us to understand better. I conducted my research in a clinic located in a safe shelter for people on the move on the border between Italy and France. That worker engage in the setting are nurses working for a small local NGO and volunteer physician. There is one health worker on shift for attendance about 70 different user each shift. Upon arrival, shelter guest undergo a quick triage. Details are taken, age, origin, migration route, past and present health issue, and vaccinal status have asked. We can already cross-reference two of the theoretical communication issue, the language barrier and the timing of the visit. Their demographic of arrival at the shelter vary over time, but for the past three years, the majority of arrivals have been people from Iran, Afghanistan, and Pakistan. None of the doctor or nurses involved in the project speak fluent Farsi and Pashto. The most common has spoken languages in those countries. It is true that some of the users pick at least basic English or French, but that is not always enough to express their health needs or their doubts and hopes about their physical state. As one of the shelter users, a guy with excellent English and high level of education told me, "When I'm sick, and when I'm worried for my health, I'm no longer bilingual." As you can guess, in this context, communicating information about prevention and vaccination is really complicated. In the word of one nurse, "How can I explain to a person who does not speak my language, who do not speak a common language well, that the vaccine is safe, that is necessary if I already struggled to explain it in Italian to my Italian patient." When you do not speak the same language to your patient, there is always a level of uncertainty or whatever your patient, not the family member or friend or combined the patient, actually understand what you're talking about. Where communication fail, these lead to feelings of dissatisfaction and frustration among both user and providers. The second issue is that of time. Explaining complex concepts requires taking long time, long minutes, and not always in the hubbub that forms at the shelter as people arrive between pressing needs such as rest, a proper meal, and a shower, and carrying for those who arrive with injuries and damages, medical issue is it possible to take. Yet, time is precisely one of the variables that will be easiest to act on and most influential in creating listening and understanding. Time is also a way that it used to govern migration. Instead, creating space where time is not constrained, but it's available to the migrants, create a moment of exchange and safety. The third problem, evident in the observation of shelter activity, was that of contextual knowledge. Most of health providers were surprised in a very negative way by the refusal to stay an extra day at the shelter to perform the vaccination. Communication was mainly based on stressing the concept of the need to vaccine to safeguard one's own health and the health of those close by. As the immigrants don't know these things without achieving significant results. Not all of the health worker were intimately familiar with the problems of the migration route and the effects of immigration health of this root, nor were they familiar with issue related to health documents as a vaccination passes. As you may have heard that in previous training of this periscope module, people on the move understood vaccination as another requirement and often another obstacle in their migratory journey. Vaccination was understood not just as an health-related choice, but rather were centered on mobility needs. Many of them had seen their vaccination paper shredded or withheld at their Bosnian border, as if they were actual passports. The main need is to move and to move fast along the borders. There is no lack of awareness of the need for the vaccine, nor do conspiracy theories prevail. But knowledge of the normal timing of vaccination, at least two weeks between one shot and an order, and the normal side effects such as fever and exhaustion that are well-known by the migrants, make refusal of vaccination, and almost obligatory decision in these settings. Being aware of the background of these people, and how the pandemic has affected their life, which is very different from ours especially the Italian population, is essential to establish effective communication in those unethically health buck that includes the or can include vaccination for COVID-19. This example related to the topic of vaccination from COVID-19 led to a question that is easily translatable to many situations I encountered in the health care of people on the move, wherever I'm pulling humanitarian settings or in public hospital the first gateway to the national health care system, I'll achieve effective communication with people on the move. We have three suggestions. First, eliminate or bypass language barriers. For example, using a translator from similar immigration backgrounds is very helpful. Second, it is necessary to take time creating a safe time for listening and explanation is crucial only after the patient values and preferences have been clarified with the physician and the patient be able to make truly collaborative decision that are in the patient's best interests. Third, it is necessary to be aware to the contexts and journey of people on the move. Not only of the clinical implication, but also of the political implications of health, hence, health is positive. Thank you for the attention.