2. LANGUAGE AND INTERPRETATION
➤ Phone Interpretation
Language and interpretation challenges are major factors in the effectiveness of health care provision for refugees and other newcomers. Eastern Health uses a telephone interpretation service, however health care providers often:
-
Don’t know about the service
-
Don’t know how to access the service
-
Don’t think they need the service
-
Would use the service if they could access it, but it is unavailable
-
Would use the service, but don’t know which language to ask for
-
Would use the service if it was better – but now the service has been upgraded
“So let’s say the patient is from Syria or Iraq and then you have an interpreter that is from Sudan. So, they [interpreters] speak Arabic, but there’s sometimes a lack of understanding that the dialects can be quite different. So I’ve seen a situation of the patient sitting there, just kind of trying to take it all in, and then leaving and saying ‘I didn’t understand anything’. So then the doctor doesn’t know that the patient didn’t understand” [Informal support worker 1]
➤ Live Interpretation
Live interpreters are sometimes required, especially for a rarer language or when there is sudden need (as with emergency room visits). This can lead to misunderstandings and disparities in interpreter payments, especially when arrangements are made outside of the formal Eastern Health and ANC processes. Many health care providers are not familiar with how to arrange an interpreter through the ANC.
“Sometimes we do have an interpreter but that interpreter is a friend or in a family relationship, then we can’t use that interpreter to interpret for a medical appointment … For Arabic we do have a good number [of interpreters] … but for most of the African languages we have lots of difficulty, like Swahili, Tigrinya … Especially when the client is a lady, I absolutely can’t send a male interpreter with her … Even if it’s a dental appointment, she would prefer to have a female. The African languages are really difficult to get honestly” [Formal support worker 2, Interpreter, refugee patient]
“Participant: And I have to go along with [the interpreter] because the interpreter is not acknowledged as an interpreter until somebody with some authority is present …
Fern: And then you’re able to bill [EH] for the cost of interpretation if you’re there?
Participant: Don’t ask me that question because we’re in a serious interview and I don’t want to laugh” [Formal support worker 6]
➤ Training and Support
Providing health care services through interpretation requires certain skills, both on the part of the health care provider and the interpreter. Those who do interpretation have a widely divergent range of training and experience and level of English proficiency. Interpreter skill can be lacking, especially when using informal volunteers.
“I have seen what appears to me to be remarkably proficient interpreters and then others that seem to me to barely be able to cope in English. They can speak their language, they can speak Arabic or Swahili or whatever perfectly but their ability to interpret it into English can be quite limited. So I would find this to be a serious concern and I’ve encountered it many times, many times” [Informal support worker 1]
Interpreters and community support workers also reported that it is a challenge working with physicians, nurses, and others who do not know how to work with interpreters. For example, clinicians may:
-
Use an inappropriate interpreter such as a child or other family member
-
Speak directly to the interpreter instead of the patient
-
Speak in long segments, speak too quickly, or fail to pause and check in with interpreter
-
Use too much medical jargon
-
Not ask for the patient’s point of view
“For example, in Swahili I have to find the way that I’m going to translate it, when there is a specific word in medicine that is difficult to translate … So you have to tell the doctor, ‘Let me try to explain it’ … For me this happened many times” [Refugee patient 8: formal and informal support worker and interpreter, man, Swahili speaking]
There is also a lack of support for navigating the ethical dilemmas and moral distress that can come with interpretation. For example, when physicians do not ask for, or patients do not offer, relevant clinical information, this can be distressful for interpreters who may feel morally obligated to step in and provide such information. These and other kinds of miscommunication can distress interpreters and lead to problematic medical outcomes.
➤ Appropriateness & Consent
The use of interpreters also raises concerns around modesty. An interpreter might be a good match with a patient for language (that is, there are no dialect challenges), but the interpretation will be unsuccessful because for social or cultural reasons the patient is not able or willing to reveal information to that interpreter. The challenge with these scenarios is that the patient may be unable (for the same or additional social or cultural reasons) to tell the interpreter that they would prefer another interpreter. This issue of how to obtain consent for use of an interpreter is underrepresented in the literature as a concern, yet poses enormous difficulties at times. This is most evident with respect to gender matches and modesty, but is equally problematic for power relations between interpreter and patient within small communities.
“One of the big issues, and we brought this up with privacy and confidentiality recently in one of our meetings at [names specialization] because as you can imagine there’s extreme intimate details being spoken about: sometimes both the couple, the man and the woman, don’t speak English. So now you have a third party talking about every part of your [intimate health details] … and we’re getting consent for a translator. So the translator is translating the consent to the patient [about whether or not they consented to using a translator, or consented to using that particular translator]” [Nurse 2]
Similar problems arise with respect to the use of informal – particularly impromptu – interpretation where the patient is being reached by telephone. In such cases it is difficult to know whether or not a patient is in fact okay with having personal health information discussed with a third party.
➤ Interpreters as Culture Brokers
Interpreters often do more than interpret; they can serve as enormous supports to patients and families, including helping to navigate the system and helping to “broker” the cultural gap between patients and providers.
“They have to ask if you’re drinking alcohol or if you are having multiple sexual partners. Some client will think that’s not nice … So I went back to the clients and tried to reassure them, try to make them aware of the Canadian culture and the questions, and you just need to answer it. But also for [the health care workers] I felt they, they were not, they are asking the question, they are very nice with the clients but they were a little bit hesitant” [Formal support worker 2, Interpreter, refugee patient]
“[The physician] wanted to shake hands with her, and I wanted to say [to the woman] that ‘You can do it’, or ‘That’s okay’, but like I couldn’t; like – it was so embarrassing, she was so embarrassed and she didn’t do anything and her husband was with her” [Formal and informal support worker 5, interpreter, international student, recent immigrant patient]