DE Piloting Report – P5 NTL e.V. MediCourse for Refugees – Learning German via doctor-patient-discussion for chronical ill refugees, pregnant women and parents of small children. (The pilot already resulted in an ongoing project and is therefore called program or MediCourse.) Place The program takes actually place in the town of Erlangen in three shelters for refugees. The majority of the learners live in residential metal containers, set up by the community of Erlangen. Others live in mini-apartments in very cramped conditions. Sometimes a tiny office in the container is available for lessons. Some learners have lessons in their rooms or in the communal kitchen. That is, because most of the learners are not mobile. Timing The program started in May 2014 and is ongoing. Currently there are lessons for small groups of 2-5 learners on Monday, Tuesday, Wednesday and Thursday. Every small group has one lesson (75 min.) per week and learners do homework from lesson 3-5 on. Most of the groups started, still exist and have become stable. We have lost some few learners due to long hospital stays and other reasons. For the total amount of lessens given, please have a look at annex 1. Target group The target group for ‘MediCourse’ are refugees with an increased need for communication with the physician and the medical staff. These are: chronically ill adults, pregnant women, parents with very young children (0-3) or parents with chronical ill children. The age ranges from 24-65. Current learners or their family members suffer from: Renal Failure, Diabetes, Depression, Asthma, Cancer, Migraine, Spina Bifida, HEF, severe chronic Gastritis, Heart Disease or are pregnant or have Babies (0-3). Most learners come to the course with nearly no knowledge of German but can reach some competences of the GeR A1 level, with limitations to grammar and with respect to a special vocabulary. Refugees in Germany are not hard to reach learners in a physical sense, but a lot of them are most hard to reach and motivate as learners. As all migrants living in poor and unstable conditions they are highly stressed and do not have adequate surroundings and psychological conditions to be taught easily. A continuous demand for MediCourse lessons for about 60 students was found -just in the city of Erlangen. Correspondingly high is the demand in Germany or the EU. However, MediCourse is not only a project for humanity, even though emphasis should be on this. MediCourse for refugees could also be transferred for other groups of migrants and this way help to avoid additional costs for the national health systems through more economic behavior in using the health system. Changing of behavior avoids many costs for chronical ill patients. Another important aspect is to avoid the transmission of diseases, such as HIV, hepatitis, tuberculosis, etc. caused by the enormous increase of migratory movements towards Europe. This way, MediCourse is not only an aid to migrants, but can also serve as a protection for the citizens of the countries of immigration. Learners’ needs If refugees need a physician, often there is no volunteer interpreter available to translate the regular doctor-patient-talk. But there is a strong need to communicate with the medical staff.
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For some of our chronical ill learners it could be a question of survival. In addition to the general physician-patient communication, some learners need instruction to rules of conduct in relation to their disease. This applies, for example, in chronic gastritis diet rules or codes of conduct for HEF. Nevertheless, there are numerous problems. 1. Where do I go with what problem? 2. How can I provide Information for a safe diagnosis 3? Do I understand a treatment and a therapy plan? etc. In a case of urgency, the chance to be understood properly goes to zero. Whether one of the medical stuff of the ambulance or the hospital stuff understands the language of the refugee, is a pure stroke of luck. However, calling the ambulance or visiting a hospital is not always a case of emergency. Refugees in general are not familiar with the German Health System. Many refugees are accustomed to join a hospital for regular and occasional treatment in their homeland instead of first visiting a general physician and having a referral to a specialist. The German system of general physician and referral to the specialist is quite unknown for many foreigners. Therefore, ‘basics of the German health system’ is part of the lessons. Directing migrants through the health system avoids costs, because treatments in the hospital cost a multiple of the regular health care visits. The evaluation of learners needs resulted in six Modules: 1 Can signal an emergency case to everybody, even at the phone (phone 112) 2. Make an appointment / application / history form 3. Understand examination / treatment / therapy (-plan) 4. Use of the picture book at the doctors’ 5. My Disease - individualized disease-related information 6. Where to go with a medical problem (Basics of German health system) As there is a strong need for learners to communicate actively, most part of the lesson is hold in interaction of learners and role-plays. Once a bit of vocabulary is introduced, learners start to ask each other questions about it and reinforce the statements with body language gestures to prevent misunderstandings. Some of the learners need extra pre-lectures on the Roman alphabet and in pronunciation. This concerns mainly learners whose native language is not written in Roman characters and learners who have not yet learned a European language, or have learned it by grabbing some components on the street. Even here, lessons are playful and hold with permanent interaction of learners to make all learners familiar with the Bazaar concept of learning. The learning space is not optimal, but we consider 'learning environment' not only as a physical place. Most of the refugees are highly stressed by their social situation and many of our learners are additionally ill. MediCourse is composed to be a little 'shelter' itself for the refugees. An atmosphere of safety, trust and empathy is one the key success factors for the motivation and efficiency of learning to this target group. Activities done and tools used Actually 18 (from initially 22) refugees join the program with regular lessons one time per week. 82, 5 hours of lessons were given from May to end of October. Not all learners join the ‘class’ every week, as some of them have been hospitalized or are sometimes ‘too bad to come’. For a precise indication of learners, learning groups, hour numbers and reasons for participation, please see annex 1. The main tools regarding medical terms and items are the medical picture books from Setzer publishing house, available in 14 languages. The picture books were developed by physicians and are not designed for teaching purposes. They are not perfect as a didactic
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material but their overall advantage is that physicians will immediately understand the terms and items. Every refugee who joins the course (of about 24 hours for a learner who knows Roman characters well) gets his own picture book to take it to the doctor and to the hospital. As all pictures are underlined with the related items in German and two other languages, the learner can name and also show the term to the doctor to avoid misunderstandings. Many other tools for general use in language learning and alphabetization are in use. In addition, all objects and everyday materials are used as learning tools, if they can support the learning process. E.g., a plush rhino, named ‘Rudi’ is regularly used as a baby having problems. Shopping brochures are in use e.g. to know food that is good or bad for gastritis. Gastritis is a very common problem, as learners constantly suffer from stress through conditions of uncertainty and bad housing. The teachers’ attitude is an important tool for learning efficiency. It is crucial to create an atmosphere of trust, to show empathy, to celebrate small successes and to thus create a safe learning place, the students like to visit. Activities and content relevance The Bazaar concept in activities and contents Based on Bazaars concept of life relevant learning, the life relevant subject of NTLs pilot is ‘Health’ and learning German via learning ‘doctor-patient-discussion’. The working hypothesis was: ‘Health’ is extremely life-relevant for the target group. Therefore learners will be highly motivated to join the course and this way acquire language skills. The contact was facilitated by social workers and volunteers who knew where to find members of the target group. Lessons were given only in small groups (2-5 people) for various reasons. 1. Target group is mostly not mobile and/or has no means for transportation. 2. It is essential for the training that there is a proper understanding of the vocabulary of the doctor-patientdiscussion to avoid miscommunications. The life relevant subject ‘Health’ is supported by liferelevant teaching methodology. The methodology reflects the ‘daily use’ of the doctor patientdiscussion and therefore requires adequate behaviours and actions in the class. The permanent use of role-plays and interactive exercises (peer-to-peer) reflect the doctorpatient-talk. Students not only learn vocabulary and related questions and answers, but also to present them in body language. This has to be practiced intensively in order to overcome the natural shyness towards 'authority figures' (medical staff). There is also a need to express actively, that something ‘was not understood, or not true or is unknown’. As a general rule, the ‘teacher’ speaks one-third of class time with the learners, the learners speak two thirds of the time with each other. The teacher will accompany the learners, help, moderate and correct but most action is required among the learners themselves to avoid any passive consumption and make the lesson most efficient. Learners also take the role of peer-tutors. In many peer-to-peer exercises, learners are asked to assess whether the answer given to them by the peer learner(s) is right or not, or to help to find the right answer or to explain with all possible means (words, body language, drawing…). Every lesson has a natural rhythm of 1.repetition, 2. learn something new, 3. practice the new, and 4. homework at the end. The groups were separated by gender, so as not to hurt the feeling of shame with delicate medical topics. Outputs and results The main outputs are capacity building for the actual first groups of learners and to develop an adequate learning system in accordance with the needs of the target group and the
3 regarding Two learners asking each other questions about nutrition Gastritis
Bazaar approach of ‘life relevant learning’ as described above. However, activities do not only regard the actual MediCourse learners. NTL not brought the Bazaar concept to own coaches but also to an interested group of language teachers from a regional registered charity EFIE e.V. for refugees. In parallel, multiple actions for the sustainability of the project were taken. NTL has also built a long-term cooperation with Setzer publishing house for the supply of the very special medical picture books. Every student who joined the course gets his own medical picture book as a final present. NTL rents boxes with medical picture books to hospitals, medical centers etc. If the medical stuff knows the picture books as well, there is an even better chance for a successful communication between doctor and migrant patients. Often the medical stuff is buying the quite unknown picture books. For every book bought by the mediation of our program, we get a credit from the publishers of five Euros. For these credits, we can then retrieve new picture books for the learners. This cooperation ensures the sustainability of the project and avoids copyright problems. There were no other cost-free materials available to teach a proper and safe understanding between the physician and the patient. Please see a sample of the picture book at http://www.tipdoc.de/grafik/pdf/Blick-insBuch-tipdoc_Prof.pdf Helping Hands during the pilot Currently three physicians are actively and voluntarily involved in the project, evaluating learning goals and lessons from the doctor’s view, visiting selected learners for special lessons on individual health issues etc. As we are not doctors ourselves, we have to ensure that what we do is safe and correct regarding the medical perspective. A group of students from the computer science industry is actually building an (unrestricted) website, to provide our information, manuals and materials to satellite projects in other regions and hopefully soon in a European context. Of course MediCourse website and materials will be linked to the original Bazaar website. Other students create a handbook on 'intercultural communication in the doctor-patient-dialogue' for the program. That is with help of one of our doctors who had a long career at ‘medicines sans frontières’. Another group is actually creating a fundraising campaign for the purchase of additional teaching materials and workshops for volunteer teachers. After the official end of Bazaar project, the coordination of MediCourse is run by NTL in cooperation with those responsible of the city, the registered charity EFIE and the volunteer helpers. The University of Bamberg and the study program vawi.de decided for a permanent ‘technical sponsorship’ of our program. Since the situation of refugees in Bavaria is so problematic, there are actual discussions to foster the capacity building of satellites with additional means. Difficulties and outcomes and Lessons Learnt People who live in a psychologically, socially and financially unstable situation, are clearly hard to reach learners and need a lot of motivation and encouragement on the part of teachers. One might think that this target group reaches for any chance to learn the language. This is true for some, but by far not the most. It should be taken into account that being introduced by trustworthy facilitators, tailored learning materials and life relevant learning objects are success factors. A language course for our target group always includes a little social work. Learners have found a contact partner and have many questions that go beyond teaching objectives. A good balance needs to be found for the volunteers. Sometimes the ‘external questions’ can be integrated to reach learning goals.
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To get stable learning groups, the language ‘status’ should be determined first. If the prior knowledge in a group of learners is too far apart, it is a major source of instability for the course. Participants with more knowledge can be ‘engaged’ as peer tutors. Coaching for volunteers is a time consuming activity if it comes to medical issues. It is essential to carefully train the volunteers, how to explain the medical terms with the help of the picture book.
Further reading For the stories and the learning materials about this piloting please visit the Blog of the project: http://www.bazaarproject.eu/blog/ and particularly: For all the other products please visit the Resources page of the Bazaar website: http://www.bazaarproject.eu/en/resources For a quick interaction, for news and for any comments and feedback please visit our Facebook page: https://www.facebook.com/BazaarLearnAndExchangeAtTheMarketplace?fref=ts
Annex 1 next page…
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Annex 1 Participants and Learning Hours May – 10th of October 2014 Small Group
Start
Place
Participants
On-site Lessons (75 min.)
Lessons in total of minutes
Armenia
May 2014
Keltstr.
5
19
Ethiopia 1
May 2014
Michael-Vogel Str.
4
Azerbaijan 1
June 2014
Schallershofer Str.
Azerbaijan 2
July 2014
Ethiopia 2 Russia/Armenia
Group Syria Registered learners for next group starting
Learning hours (Learners x Hours)
Special needs
Group still active?
Remarks
1425
Lessons in total of hours 23,75
118,75
Dialysis Diabetes Depression
yes
7
525
8,75
35
Small Childs Asthma
No
Slow progress because of cognitive restrictions in connection with med. Prob. 2 learners changed to another daily course, for 1 we couldn’t organize childcare, 1 moved
5
16
1200
20
100
yes
Keltstr.
3
14
1050
17,5
52,5
August 2014
Schallershofer Str.
2
7
525
8,75
17,5
September
Schallershofer Str.
3
3
225
3,75
11,5
Pregnancy Cancer Migraine Small child Small child Spina Bifida HEF Small Childs Gastritis Cancer Depression
22 4
66
4950
82,5
335,25 Small Childs Heart disease Depression
6
yes yes yes
The learners invited other refugees to the lesson who joined it occasionally