TRICC Logo
Lifelong Learning Programme
Lifelong Learning Programme, Grundtvig - Multilateral Project
Project no.: 142235-2008-LLP-NL-GRUNDTVIG-GMP
Project title: TRICC - Training Intercultural and Bilingual Competencies in Health and Social Care
Interdisciplinary Social Science Department
Utrecht University

Utrecht, the Netherlands
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Boğaziçi University
Istanbul, Turkey
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COOSS Marche
Ancona, Italy
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dock europe e.V.
Hamburg, Germany
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PPRE Limited
London, Great Britain
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Research Methods

The assessment of training needs is based on earlier findings within the previous project BICOM as well as scientific studies and publications on ad hoc interpreting (BICOM: Needs of good interpreting service - PDF). This knowledge was extended in the TRICC project by conducting group and individual interviews with different target groups to develop the training modules geared to the respective needs.
Featured here are the interview guidelines used, as well as the training needs assessed in interviews and discussions with different target groups.

 

Experiences of general practitioners with interpreters (Netherlands)

Aims: This research has been conducted in 2009 by Utrecht University, in order to gain insight into the knowledge, opinions, and experiences of general practitioners (GPs) with regard to the use of interpreters when communicating with patients with poor Dutch language proficiency. The results of this research will be used to develop a training programme ‘The bridging of language barriers in general practice’.

Method: Dialogical interviews were held with eleven general practitioners (5 men and 6 women), all of them working in multicultural neighbourhoods in Rotterdam. A topic list was used as a guideline for the interview. The interviews were held individually, and took about 45 minutes in average. All interviews were audio recorded and transcribed. These transcripts were verified by a second researcher.
The transcripts were analyzed by Maxqda, a computer program for qualitative data analysis). The interviews were coded along the following categories: experiences, policy, alternatives for interpreters; interpreter preferences; children as interpreters; communication and training wishes.

Results
Experiences: GPs report more experiences with informal than with formal interpreters. About the same number of good and bad experiences with formal and informal interpreters were reported. GPs like to work with informal informal interpreters, because they provide extra information about the patient and the context of the illness. However, GPs appreciate that formal interpreters translate more accurately and the fact that they provide information about the translations made. Moreover, GPs would like interpreters to operate not only as translator, but also to serve as a cultural bridge between the doctor and a patient. GPs consider it as aggravating if the informal interpreter intervenes too much in the medical communication process, when discussing medical complaints, diagnosis and/or treatment, proclaim her own demands and/or dominate the patient. Poorly motivated interpreters (as children) are also considered to be aggravating. The most salient concerns about the formal interpreters are the trust-issues (patient have little trust in the formal interpreters) and the difficulty in organizing the contact with formal interpreters for the consultations.
Policy: Most GPs do not know anything about the official policy concerning the use of interpreters in the health care. They usually do know about the possibilities to require a formal interpreter trough the Dutch Interpreter- en Translation Centre (TVCN). Nevertheless, the patients are usually kept responsible for bringing an (informal) interpreter with them. This is in contradiction with the official policy, where the physician is responsible.
Alternatives for interpreters: beside the use of informal interpreters (family members or relatives), GPs work with a range of other ad hoc sources, like bilingual assistants, care managers, care consultants or nurses for interpreting provision.
Preferences: Most GPs prefer informal interpreters, because it is easier to organize while patients provide an interpreter. However, its is dependent on the type of the medical complaint, the delicacy of the situation, the language skills of the patient and his social network to decide which type of interpreter (formal or informal) can be used best. When the complaint concerns a relatively simple, somatic issue, GPs often prefer an informal interpreter. If the complaint is more complicated and/or psychosomatic, GPs often call for a formal interpreter. When the patient speaks a little bit of Dutch, GPs prefer to talk to the patient without the involvement of any interpreter. If the language proficiency of the patient turns out to be insufficient, an interpreter is called. Also, when the patient has no friends or relatives to bring along, a formal interpreter will be arranged.
Children as interpreters: Although children are often used as interpreters in medical consultations, GPs consider this situation as undesirable. Nowadays, the situation of ‘children as informal interpreters’ is less tolerated than in the past. GPs consider it ethically wrong to involve the child in the parents’ problems. As the time passes, GPs usually become aware of the enormous impact that interpreting can have on the child, but it seems difficult to change their behavior. Communication: If there is emerging a long chat between patient and interpreter, GPs usually doubt the correctness of the translation, if only a small part is translated to the GP. GPs considers these ‘side talk activities’ rather unpleasant, since they might loose control over the situation. According to GPs, the involvement of an (especially informal) interpreter may affect the clear communication between the patient and the doctor substantially. The interpreter presumably changes the utterances of the primary speakers in his own mode. GPs especially appreciate face-to-face communication and because of this they often explicitly decline telephone- interpreting.
Training wishes:GPs indicate a lot of methods which presumably will help them to change their behavior. Especially role plays are very much valued. The sharing of experiences, the use of videos, case discussions and information sharing are also considered fruitful. Nevertheless, most GPs have no clear ideas about which method will be most suitable for them to change their behavior.

Conclusion: GPs frequently work with informal interpreters, and have ambivalent feelings. There is a need for more knowledge about policies, about possibilities, and about educational tools which will give insight and awareness; especially they like to practice new behavior.

This text is a summary of a project in which general practitioners were interviewed; it was performed as part of the TRICC-project “Training in Intercultural and Bilingual Competencies in health and social Care”.

Utrecht, March 12, 2010

Download nederlandstalige versie (PDF)

 

Questionnaire Guide (Germany)

Developed by Ortrun Kliche, Birte Pawlack, and Bernd Meyer within the Project “Development and Evaluation of an Interpreter Training Module for Bilingual Hospital Staff” at SFB 538, University of Hamburg

Experiences of interpreting (in the hospital)

Please tell me how you generally started interpreting.

This includes all forms of interpreting: in a private setting, for family, relatives or relations but also in the context of the workplace.

Please tell me about an interpreting situation in the hospital which you remember well.

Now please relate another interpreting situation which you remember well because it went well/badly (opposite of the former situation).

And now I would like you to relate another interpreting situation in which you hat to deliver „bad“ news, i.e. a negative diagnosis or had to explain the risks of a procedure or surgery (e.g. complications of a gastroscopy).

How do you deal with interpreting “bad” news?

Now that you have already described a few interpreting situations, please tell me what a typical, normal situation where you do the interpreting looks like.

Do you enjoy interpreting?

What are the major common problems you encounter as an interpreter in the hospital?

Which of these problems are most significant? Which ones come second etc.?

Interpreting skills

What do you think doctors expect of you as the interpreter?

What do you think patients expect of you as the interpreter?

How do doctors deliver bad news? Do they do it in different or similar ways?

Spare questions

  • Do you interpret during working hours or before/after work?
  • Who takes over your duties when you need to interpret during working hours?
  • How is your service organized? Are you informed by phone? Who calls you?
  • How do people know about you? Do the doctors know you personally? In all departments? Or is there something like a directory of interpreters? How were you included on this list? Is there a person who coordinates these services? Is there a reward for these services financially or in form of leave? What else can you think of concerning the organizational framework?
  • How long does it take you to get to where you are needed as an interpreter?
  • How long does an interpreting assignment usually take?
  • Are you able to prepare for the interpreting assignment? If so, how? Do the doctors usually give you information on the patients?
  • Is there also an in-depth follow-up of the interpreted dialogue?
  • Does the patient/doctor give you feed-back on your interpreting? (thanks, praise, criticism)

Expectations concerning the training

What do you personally want to learn/improve during the training?

What would you like to exchange on with other participants?

Are there any other requests you have for the training sessions?

Professional background

Since we don’t work in your field, maybe you could tell us the exact title of your job?

Which department of the hospital do you work in?

Where did you do your professional training as a caregiver?

When did you start working as a caregiver?

Since when do you work at FEK?

Language Acquisition Biography

Where were you born?

What is you mother tongue?

How long did you live in your country of origin?

Which schools did you go to?

When did you learn German?

How did you learn German (in your family, in language courses, in school, somewhere else)?

What language did you do your training in?

Since when and how often do you interpret in the hospital?

Which language do you feel more at home in when it comes to medical topics?

You know both languages well – German as well as XXX. What are the major differences you see between both languages?

Conclusion

What would the best possible organisational process look like for you?

What, according to you, would improve the interpreting situation in the hospital?

 

Ad hoc Interpreting in the Hospital (Results, Germany)

1. The Organisational Set-up

In general, an improvement of individual interpreting skill is inextricably linked to a sound organisational integration as well as a clear positioning on the part of the administration in which language support is regarded as an aspect of patient care. However, on the administrative and organisational levels of most hospitals there is a lack of both consciousness as well as support, as the personal and phone interviews we conducted with heads of patient care and human resources departments showed. Without changes made here, we must state a priori that, realistically, hardly any sustainable outcome can be expected of the training module.

It could even have the opposite effect (as in homeopathy): only a small amount of knowledge and insight is administered and the situation might become even worse. Employees who have gone through further training will be more self- confident and may be better able to set boundaries which could create conflict. Apart from this, caregivers who have undergone training for ad hoc interpreting may be under a certain pressure to prove their skills and to complete the interpreting assignment successfully. If they are not successful they carry a lot more responsibility.

In a constructive approach, the organisational grievances are to be addressed during the training, they are to be identified as critical points and extracted. Possibly the administration can be provided with a report after the training which describes the contents of the training and additionally, in a sort of catalogue of recommendations, states the importance of support on the part of administration as well as a good organisational integration of interpreting services. It also makes sense to point out the organisational set-up when we evaluate how successful the training was and cannot register a great improvement.

2. Requirements that are of relevance for the training of healthcare staff functioning as ad hoc interpreters in the hospital.

Based on 8 interviews conducted by Ortrun Kliche and Meike Bergmann

5 women of Turkish, Russian, Russian-Ukrainian and Russian-Greek background undergoing a compact training as healthcare and patient care professionals. (The 22-month training is geared to persons who have already completed a professional healthcare training in their countries of origin which is not completely recognised in Germany; they have good German language skills on B2-level). All interview partners have already worked as nurses in their country of origin for several years.

3 registered nurse with a Russian, Portuguese, Iranian background. The Russian nurse completed her 6-month preparation for the assessment test about half a year ago. (Requirement: occupation in the German health sector at the time of the assessment test). The two other nurses did their vocational training in Germany and have been working in German hospitals for 14 resp. 15 years now, both in the geriatric ward.

At the same time - functioning as a comparison - there is a group of test persons consisting of 6 registered healthcare and patient care professionals who were also interviewed and who will get a training within the framework of a university project.

The interviews were conducted using the interview guidelines that were already introduced. One of the objects of the interviews is to identify the special requirements for a training for ad hoc interpreters. Secondly, they serve as an evaluation of the training (in conjunction with interviews that are conducted after the training).

Training requirements (only those requirements which exceed the list of needs from the BICOM project are listed here):

  • Development of the role of the ad hoc interpreter
  • Interpreting in a triad setting
  • So-called distance interpreting
  • Interpreting for patients with limited command of the German language.
  • Responsibility and liability (for example: what happens when a patient claims essential information was not interpreted?)

Ortrun Kliche
dock europe e.V.

 

THE RESEARCH METHODS AND RESULTS IN ITALY

The research was conducted in the Hospital of Jesi (IT), a town with a high percentage of migrants living there. The hospital provides an internal interpreting service provided by professional mediators from different countries. The research purpose was to investigate the quality of the health services provided to migrants by the hospital, with particular focus on the communication aspects. Formal interpreters/mediators and migrants who had attended the hospital were selected for the analysis of needs, and tailored guidelines for interviews were designed. In general, the interviewees were encouraged to talk freely, with the interviewer leading the discussion back to the basic topics when it tended to diverge from the research key points. The interviews were led by a psychologist, audio recorded and transcribed

Interviews to migrants

Four immigrants from different countries (Ex-Yugoslavia, Congo, Bangladesh and Nigeria) were interviewed, to know about their experience with formal and/or informal interpreters, their experience as informal interpreters (if any), their perception of the health system in Italy, and their perception of bilingualism as an empowering value.

Results: all confirmed the negative feeling of living in a foreigner country without managing its language. They reported the difficulty to trust an informal interpreter, even if all of them had acted as such for their parents/friends/relatives at least once. They reported it was quite a good experience, especially because pleased to help relatives and friends. The health assistance received in Italy resulted satisfactory and adequate to their needs. All consider bilingualism a value, and 3 against 4 would like to get a qualification as interpreter/mediator.

Interviews to mediators

Six cultural mediators coming from different countries (Brazil, China, Morocco, Albania, Ex-Yugoslavia and Congo) were interviewed, to know their motivation to the profession, the training they attended, their further training needs, and some real cased they had experience of.

Results: all referred to feel somehow emarginated by the health professionals and acknowledged a poor culture of the “mediator” within the service they work into. This made COOSS staff reflect on the opportunity to reconsider the target group initially identified for training. Professional mediators seemed to have the competences to perform their job properly, while the main problem resulted to be the poor attitude and sensibility the health staff demonstrated towards “mediation”. Promoting mediation and proper communication among the health personnel appeared to be a worthy challenge, and it was decided to carry out additional interviews to doctors, nurses and health professionals.

Interviews to health staff

Health professionals working in those hospital units daily attended by a high number of migrants were interviewed: two Psychologists, a Gynaecologist, a doctor from General Medicine unit, a doctor from the First Aid unit, a Paediatrician.

Results: all referred to have experienced some problems with migrant patients, especially with Chinese ones, because of their very poor Italian language proficiency. Only a few doctors and psychologists had accessed the mediation service active in the hospital to solve these problems, while the majority of them even ignored its existence. The greatest part of the interviewees thinks that a mediators might be useful when a translation problem occurs, especially with Chinese patients. It stresses the trend to associate the word “mediator” and “interpreter” in their meaning. Doctors are used to help themselves as they can, calling a friend or an acquaintance able to “translate”. Some consider unfair to ask relatives to “translate”, as, being emotionally involved, they might distort translation: nonetheless, it happens to involve relatives when no other alternatives are available. They acknowledged that using children as mediators is wrong but, missing alternatives, they admitted to have recurred to them. Many admitted to ignore the existence of the interpreting service within their hospital, and others to have never used it. The gynaecologist referred that when Moroccan, Chinese, Indian women are accompanied by their husbands or children, the communication is laconic, the answers limited to yes/no, with the power evidently in the hands of the person who manages the language. When, conversely, a formal interpreter is present, the women speak much more freely and ask for clarifications. On their part, the doctors are more at ease as they can trust the mediator’s translation interpreting reliability.

Conclusions

Health professionals revealed to have poor intercultural background and sensibility: to raise awareness on intercultural dialogue and mediation among health professionals was the objective of the training course COOSS designed and implement within the TRICC project.

 

Informal and Ad Hoc Interpreters (England)

The experience Of Turkish people In Hackney, London, U.K.

Background

The aim of this project was to audit the extent of the use of ad hoc interpreters in the Turkish speaking community in general practices in Hackney. It was believed that even though professional interpreters are often available, Turkish speaking patients frequently bring a family member, friend or someone whom they feel close to interpret during their consultation. We wanted to interview both ad hoc interpreters and users of such interpreters.

The project covered nine GP practices in Hackney and a Turkish supplementary school. The research took place at Easter 2009. The “Easter” break was a problem in terms of reaching supplementary schools as they go on a break with other national schools. Many schools were approached by calling them, writing or emailing. Only Day-Mer Turkish/Kurdish Community Centre agreed to take part. Berkley Community School explained that because of their location, majority of their attendees were already from Turkish/English speaking parents. It was agreed that their involvement may not be relevant to this project.

The short period in which to carry out the fieldwork led us also to approach some members of the “Turkish speaking public” at various locations from Hackney and North London who fitted the criteria; however the overall setting did not differ. The same questions were asked as if they were waiting in the GP surgery. The questions were prepared in a general outline, giving room to discuss related issues openly and many who took part felt, it was appropriate to ask further questions as well as giving their experience freely.

Four out of nine GP practices approached agreed to take part and allowed the researcher to go in to their practice.

All practices were contacted via fax, letter and phone calls. Abney House, Cedar Practice, Statham Grove and Dr. V.N. Patel agreed to take part. Other GP practices were either reluctant or not being able agree as result of absence of their practice manager. They cited the Easter break as the reason for not taking part. One practice said that they had their own data with respect to the Turkish-speaking community and involvement from ad hoc interpreters, however for data protection reasons the Practice Manager was reluctant to give the details. Another Practice did not give a reason. Once a contact established, each practice was visited.

The project had 53 participants over a four week period.

17 participants said they needed an interpreter and stated that they used ad hoc interpreters regularly. The number of female patients was greater than male patients. There were no participants below 19 years old. Among this group, a few also said that whether they try to use an interpreter provided from NHS depends on the availability of an interpreter and the level of concern with respect to their health.

Use an interpreter

Patients 19-54 (age) 55-74 (age)
Male 6 2
Female 8 1


36 participants stated that they do ad hoc interpreting regularly to family, friends or neighbours at least once a month but in many cases, once a week. The majority of those were again females aged 19 to 54 years old. However it must be noted that 11-16 years old had also a high number of ad hoc duties to their family and friends.

Have done ad hoc interpreting

Ad Hoc interpreters 11-16 (age) 17-18 (age) 19-54 (age)
Male 3 3
Female 12 1 17


10 participants stated that they do not use any interpreter at all or only on rare occasions. However, rare occasions referred to involvement with the police or court cases. Two of the female participants (aged 11-16) stated that their parents spoke English well and never interpreted for anyone.

(Almost) Never use an interpreter

No Interpreter 11-16 (age) 17-18 (age) 19-54 (age)
Male 5
Female 2 1 2


Further findings:

  1. One practice has a Turkish speaking doctor on site to provide health service to Turkish speaking community. The practice manager is also speaks Turkish.
  2. In another practice a GP has started learning Turkish but the practice also has Turkish interpreter.
  3. One patient who lives in Leytonstone (In a neighbouring borough) reported on their experience at a local hospital and their own surgery in that area. They said that the interpreters were not of Turkish origin and did not speak “proper” Turkish. There have been number of occasions where the interpreter provided by NHS did not know the meaning of certain words. This resulted in patients specifically asking for a Turkish speaking interpreter or opting for a family member rather than using an NHS service. The interpreters were either from Iran, Iraq or most often, Cyprus.
  4. Almost all participants stated that the main reason for using ad hoc interpreters was the issue of “trust”. Most of the participants said that the information they share is personal and would prefer someone close to them, in particular a family member.
  5. On few occasions, service users complained about the availability of NHS interpreters at the practices. They said that even if they wished to use an interpreter from the surgery, it is not always possible in terms of time arrangement such as clashing with other patients’ appointments or lateness from the interpreter resulting with the patient missing their own appointment.
  6. Patients complained that they can not access an interpreter on the day they wish to see their GP. Patients feel that health does not wait until an interpreting service is available. Once they need to see their GP they would like to be able to go any time they need it, not on the days arranged by the practice. it is noted that in few surgeries that the NHS interpreter is available on certain days of the week.
  7. One female participant felt very emotional while talking about her own experience. She feels that even though families bring their children, it does not seem to be a clear cut choice. After arriving in the UK 11 years ago, she asked her children to interpret. They are now aged 21 and 19 but while her husband had a routine health check, doctors had told their (then) 15 year old daughter that her father’s illness was cancer. In this case the mother still feels guilty for bringing her daughter in to the hospital. It is her wish to point out clearly that, how the hospital staff was insensitive to share such information with a 15 year old girl, while giving her the burden to deal with the emotional trauma. The girl did not share this information with either of the parents but opened up to a neighbour upon her return from the hospital. Her mother says she still feels upset, troubled and is trying to find her way in life. The participants view is that while Turkish speaking community may not have any choice but ad hoc interpreters most of the time. She would like to point out the responsibility lies with the NHS also, to be able to provide a professional interpreter on site or bring guidelines to ad hoc interpreters such as an “age limit”.

The views of young ad hoc interpreters

When speaking to young ad hoc interpreters about their role, the results were as follows:

  1. Ad hoc interpreters felt a massive amount of responsibility and pressure from the person they interpret.
  2. Most stated the difficulty involved and the psychological pressure due to lack of vocabulary and not having the necessary training within medical field.
  3. Most stated that the interpreting they are asked to do was not only for their family but neighbours and friends of their family.
  4. On many occasions, they felt extra pressure, as the person whom they interpreted did not believe them and not only had they interpret for them but also given the responsibility to assure the patient with respect to health issues, in some cases someone they did not relate to at all apart from being a neighbour. When asked how they cope with such pressure, they laughed and seemed to look at this matter as if it was something ordinary after years of practice.
  5. A few ad hoc interpreters stated that as they got older, their responsibility was greater with respect to working or studying, in effect they were not able to do as much interpreting as they used to. This may be a driver to push Turkish speaking patients to use NHS interpreter. However, it was clear at the end of the research that not all participants (ad hoc interpreters and patients) were happy with this aspect.
  6. The 11- 16 age group seem to approach ad hoc interpreting as if it is their usual routine.

Conclusions

Based on the information above, Turkish speaking ad hoc interpreter’s contribution as an interpreter to family and friends at GP surgeries is greater than expected. This is clearly an important and ongoing issue within Turkish speaking community. Unless further measures are introduced, the practice of young ad hoc interpreters will continue for sometime. However, it is also possible that bearing in mind today’s young ad hoc interpreters seem to be keen on further study, this is more likely to in the influence future generations of Turkish speakers. It must be noted that ad hoc interpreters aged 11-19 are already taking place at colleges for further study for professional careers including in health. However further immigration may sustain a need for ad hoc interpreting.

 

Ad Hoc Interpreting in Hospitals in Turkey

The Turkish partner was originally invited to participate in the TRICC project to provide cultural mirroring. In the grant application for the project, ‘cultural mirroring’ was referred to as follows: ‘The linguistic, historical and socio-cultural input of the Turkish partners will be most valuable as they serve as a critical mirror and accompanying interlocutor for any part of the project involving socio-cultural and historical aspects of Turkish migrants in Europe.’ In other words, it was expected that the participants from Turkey would provide information about social, historical and cultural aspects of Turkish minorities in Europe that have some bearing on health and social issues, at the same time as they offered feedback to their partners from Western Europe on how their training methods and materials might be perceived by members of Turkish-speaking minorities, who were initially supposed to be the chief target-community in the TRICC project. Soon into the project, the Turkish team realised that, alongside supplying this kind of cultural mirroring, they could also ‘turn the mirror’ on Turkey and investigate the state of medical interpreting in that country, especially to see whether ad hoc interpreting was as common as it appeared to be in our partner countries and to establish more detailed characteristics of ad hoc interpreting in the Turkish context.

Research on the Private Sector
A first piece of research done to this end was a BA graduation thesis on linguistic and cultural mediation services in private hospitals in Istanbul, written by Nihan Sevinç and supervised by Dr. Jonathan Ross. Ms. Sevinç conducted face-to-face interviews with doctors, interpreters and public relations and management staff from five different hospitals in Istanbul, making use of (a Turkish translation of) a ‘Topic list for interviewing health care providers’ drawn up during the BICOM project. She concluded that, whereas in some hospitals and with regards to some languages, an effort had been made to ease communication between health workers and foreign patients, non-Turkish-speaking patients could not always expect the level of mediation service that the hospital websites, for instance, would have them believe. On the positive side, in most of the hospitals doctors spoke English plus one other common Western European language (especially German), and in one major eye hospital the languages known by different doctors also included Japanese, Persian, Albanian and Serbian. Some medical tourists could benefit from quite impressive packages: their need for surgery would be diagnosed at the clinic of the Turkish hospital in their own country; then, once they arrived in Turkey, they would be provided with a bilingual ‘guide’ (also serving as an interpreter) provided by the mediation agency that arranged their travel. On the negative side, relatively few nurses had sufficient competence in foreign languages, and the number of in-house interpreters available even in the biggest private hospitals was limited to one or two, with the interpreters serving more often as translators of medical documents. Doctors and managers alike complained about the lack of interpreters for certain languages (especially Albanian) and admitted that patients without knowledge of Turkish, English or German often found themselves having to rely on informal interpreters such as family members and hospital ancillary staff. Examples of ad hoc solutions included the (fairly common) deployment of Turkish husbands to interpret for their Russian wives (sometimes over the telephone) and an occasion when an Arabic-speaking man who was working on a cruise-ship with which the hospital had an agreement was called upon to interpret for another Arabic-speaker working for a company whose employees were entitled to treatment at the same hospital!

Research on the Public Sector
As for research on issues of language and interpretation in the public health sector, we first applied to Cerrahpaşa, one of the two faculties of medicine attached to Istanbul University, to carry out a simple survey to gauge how frequently patients were unable to communicate with health workers in Turkish and what solutions were found in such circumstances. We spoke with two senior physicians in the hospital, as well as the vice-dean of the faculty, and were told that it was extremely rare for patients without any Turkish to come for examination or treatment to Cerrahpaşa. On the very rare occasions that this occurred, the language of the patients tended to be Kurdish or Russian, and in all these cases patients brought their own (informal) interpreters. In view of the doctors’ contention that cases of language mismatch between doctors and patients were ‘one in a thousand’ at Cerrahpaşa, we concluded that it would make much more sense to conduct a survey on medical communication and ad hoc interpreting in Eastern and South-Eastern Anatolia. This is because the majority of the people in these areas are Kurds, and many of them have a Kurdish dialect (largely Kurmanji but also Zazaki) as their mother tongue. Although most young people and males have at least a reasonable understanding of Turkish (the only official language and language of instruction in schools in Turkey), there are still a fair number of women and elderly people with minimal competence in Turkish. Statistics related to minorities and their languages in Turkey vary enormously and are not particularly reliable, but a reasonable estimate that has been proposed is that around a third of the Kurds in Eastern and South-Eastern Anatolia have limited or no competence in Turkish. Dr. Selçuk Mızraklı, former chair of the Diyarbakır Chamber of Medicine, has pointed out that since one third of local citizens do not know Turkish and two thirds of the doctors working in the region do not understand Kurdish, there is considerable potential for communication problems.

In order to gauge the frequency of mediated doctor-patient communication in this area of Turkey, to build up a profile of the ‘interpreters’, and to identify the main problems involved in such triadic encounters, during the summer of 2009 we carried out a survey at two state hospitals in the region (Diyarbakır and Van). Two different questionnaires, aimed at patients and interpreters, were prepared in Turkish, and Kurdish-speaking students at Boğaziçi University who are involved in the university’s Kurdish Literature Club were asked to pose the questions to all the patients entering a randomly-selected consultation room over a certain period. Unfortunately, the researchers were not able to carry out the survey in this way and instead approached patients waiting in the forecourt of the hospital, a strategy which arguably undermined the ‘randomness’ of the survey. Between them, the students managed to question a total of 54 patients and 46 companions / interpreters.

Questionnaire for Patients

  • Did you come to the appointment on your own?
  • If you didn’t, who did you come with? (member of immediate family/member of extended family/friend/professional interpreter/other-please specify)
  • What is your level of Turkish? (very good/good/mediocre/low/non-existent)
  • Did you communicate with the doctor in a language other than Turkish? If so, which language?
  • What is your mother tongue?
  • If you communicated via an interpreter, how successful do you think the interaction with the doctor was? (very successful/successful/not so successful/unsuccessful)
  • If you thought it was unsuccessful or not so successful, what kind of problems did you have with the doctor or interpreter? (open question)
  • Would you like to add anything else? (open question)

Questionnaire for Companions

  1. What is your relationship to the patient? (multiple-choice)
  2. What is your level of Turkish? (very good/good/medium/inadequate)
  3. What is your level in the other language you speak? (very good/good/medium/inadequate)
  4. Have you ever interpreted in a similar setting before? If so, how many times?
  5. Have you had any medical training? If so, what kind?
  6. Have you had any training in translation/interpreting? If so, what kind?
  7. How successful do you think the interaction with the doctor was? (successful/successful/not so successful/unsuccessful)
  8. What kind of problems did you face while interpreting? (open question)
  9. Would you like to add anything else? (open question)

The most striking findings of the survey are as follows:

46 out of 54 patients had a companion with them when they attended the medical consultation, with most companions being members of the immediate (23) or extended (19) family. No professional interpreters were used.

46 out of 54 patients stated that they communicated with the doctor in a language other than Turkish, which was always Kurdish (Kurmanji). Unfortunately, question 4 in the patients’ questionnaire (‘Did you communicate with the doctor in a language other than Turkish? If so, which language?’) was flawed in that it was not clear whether patients were being asked if they had spoken directly to the doctor or had communicated through the companion-interpreter.

34 out of 46 companions had interpreted for people before, with 10 of them doing this 10 or more times and one doing it on more than 50 occasions!

26 out of 54 patients who required an interpreter said the communication with the doctor was ‘not very successful’, while 8 described it as ‘unsuccessful’. Just 2 thought it was ‘very successful’ and 10 ‘successful’. The fact that the total number of responses to the question evaluating the interpreted conversation (question 6) was 46, i.e. the same as the number of accompanied patients, suggests that all of the companions also served as interpreters, thus clearing up the ambiguity created by question 4.

Among the problems mentioned by patients were the following:
They did not feel comfortable speaking via an interpreter (23 respondents)
They would prefer to talk directly (38)
Doctors displayed an ignorant attitude towards non-Turkish speakers (12)
The companion-interpreters lacked knowledge of medical terminology (4)

When asked to evaluate the success of the communication between the doctor and patient, 24 out of 46 companion-interpreters described it as ‘not very successful’, 4 as ‘unsuccessful’, 16 as ‘successful’ and 2 as ‘very successful’.

The companions reported the following (among other) difficulties when interpreting
They felt they had insufficient translation skills (21)
The patient was obviously not comfortable in relating all problems while they were present (8)
The doctor’s language was too complex (3)

The most striking finding is that 46 out of 54 patients (i.e. 85%) apparently needed the assistance of an ad hoc interpreter. When we bear in mind that around a third of Kurdish speakers in that region are thought to have minimal knowledge of Turkish, 85% does seem an exaggerated figure. However, other research conducted in the area, which we actually discovered after we had carried out our own survey, suggests that a percentage above 50% would not be far-fetched. Back in 1994, the Turkish Medical Association reported on a survey carried out among an unspecified number of doctors, midwives and nurses in the main health centre in Diyarbakır (the biggest city in the predominantly Kurdish-speaking area of Turkey). Here, more than half of the doctors felt the need for a third person in order to communicate with patients. In 2008 and 2009, when 253 doctors responded to a question in a survey prepared by the Diyarbakır Chamber of Medicine about whether they had difficulties communicating with patients, 49.8% of respondents said that they did not face problems, since they knew the language spoken by the patient, 48.6% got help from a member of staff or companion of the patient, while 1.6% decided not to examine the patient.

The 49.8% presumably includes cases of doctors communicating with patients in Kurdish―a practice very much frowned upon and even criminalised until the early 2000’s. This practice is much more common today due to a marked increase in the number of ‘local’ Kurdish-speaking doctors serving in the region, as well as a great effort being made, especially by the Diyarbakır Chamber of Medicine, to improve the Kurdish competence of health-workers (whether or not they are Kurds) and to encourage doctors to communicate in Kurdish where necessary. An important part of this strategy was the publication in March 2009 of a book Kürtçe Anamnez [Anamnesis in Kurdish] which contains a potted Kurdish grammar, a bilingual (Turkish and Kurdish) glossary, and translations of questions a doctor needs to ask in order to establish the medical history of a Kurmanjis-speaking patient. A few years ago, such open encouragement to use Kurdish in a public context would have been unthinkable!

All the same, the Chamber of Medicine report reflects the ongoing use of ad hoc solutions in just under 50% (48.6%) of cases, indicating that recourse to ad hoc interpreting is actually far more widespread in this area of Turkey than it is in the other countries covered in the TRICC project.

Another striking finding is the dissatisfaction of both groups of respondents in our survey with the performance of the interpreter. This concurs with the negative attitude that health workers and health activists in Eastern Anatolia seem to have with regards to the use of interpreters in medical settings. As an example, one can cite a comment made by the then chair of the Diyarbakır Chamber of Medicine, Dr. Adem Avcıkıran, in the preface to Kürtçe Anamnez: ‘Histories and complaints of patients that are conveyed to doctors through an interpreter are unreliable. For this reason, they may give rise to wrong diagnoses and treatments.’ Similar judgments on interpreting were in evidence at the meeting ‘Anadil ve Sağlık’ [Mother Tongue and Health] jointly organised in Ankara in March 2010 by the Turkish Medical Association and the main Turkish healthworkers’ union, at which members of the Turkish team in TRICC were invited to speak.

As we stated on that occasion, it is clear that health professionals in Eastern and South-Eastern Turkey have been very negatively affected by having to rely on the linguistic mediation of patient-companions or hospital staff who often lack competence and vocabulary in one or even both languages involved, who have had no training in interpreting, and who are not familiar with any codes of ethics or standards of best practice related to interpreting. Such healthworkers seem to regard the ‘interpreters’ they have encountered as the only possible kinds of interpreters and are fairly reluctant to accept that, with some training, such as that offered by the partners in TRICC, the people now serving as ad hoc interpreters could make a more positive contribution to medical encounters between healthworkers and patients. (Having said this, it would be naive to ignore another dimension to some of the resistance to interpreting: many people in the predominantly Kurdish areas of Turkey are eager to foster the use of Kurdish by all parties in as many areas of public life as possible, thereby challenging the monopoly that Turkish has enjoyed until recently.)

Future research
A further piece of research, which we were unable to complete during the lifetime of the TRICC project, is a very detailed (47-question!) online survey directed at health professionals in Eastern and South-Eastern Anatolia. One of its aims is to furnish additional data concerning the frequency of ad hoc interpreting, which we can use to check the validity of our first survey. Another is to obtain a much more detailed and definite picture of doctor-patient encounters in Eastern Anatolia. The questionnaire contains a mixture of yes/no, multiple-choice, likert-scale and open-ended questions, which cover variables such as

  • the linguistic background of the doctor
  • the relationship between the gender of the patient and that of the interpreter
  • actions taken by the patient’s companion when the companion is (or is not) serving as an interpreter
  • the doctor’s general degree of satisfaction with interpreted encounters
  • particular faults in interpreters’ performances
  • the doctor’s preferred solution to the problem of medical communication in Eastern and South-Eastern Anatolia

We will also ask for stories of good and bad practice in ad hoc medical interpreting.

Through our contacts in the Diyarbakır Chamber of Medicine, a pilot version of the questionnaire will be sent to a group of 10 doctors, who will be asked to fill out a survey-evaluation form. After the questionnaire has been revised to take account of any suggestions these doctors make, the revised version will be published online and the link sent to all 3000 or so doctors working in the region.

 

Informal and Ad Hoc Interpreters
The experience of Bangladeshi people In East London, U.K. (England)

1. Introduction

The aim of this project was to understand the ad hoc interpreter‟s role with respect to Bengali speaking community at general practices in East London. It is understood that even though professional interpreters are often available, Bengali speaking patients frequently bring a family member, friend or someone whom they feel close to interpret during their consultations with health care providers. In some cases, the interpreter is either a young child or an unqualified relative who often does not have any familiarity with medical terminology. This brings further complications to communication and relationship between the doctor/nurse, the patients and ad hoc interpreters.

There are very many ways in which things can go wrong when communication fails between patients and providers of healthcare - common, seemingly relatively simple situations can in reality be potentially dangerous and may have serious consequences. The role of close family members like children or relatives who have none or very little experience in interpreting in medical terminology clearly brings more concerns.

2. Background to the Bangladeshi community as a case study

London has probably the greatest number of speakers of different languages of any city in the world. A forthcoming study finds that there are nearly 250 languages spoken by London‟s school children, comprising more about 40% of the children1. After English, Bengali is second most widely spoken language among school children, spoken by nearly 50,000 children.2 Clearly for every child who speaks Bengali there will be one or more adults. In fact the ratio is likely to be a little over two adults for every Bangladeshi child under 16. 3

The Bengali speaking community mostly originates from Sylhet in north east Bangladesh. The Bengal-London connection goes back at least 400 years and is intimately tied up with the history of the East India Company and the British Empire with the export of tea and a large number of seamen from the area ((Lascars‟) working in the merchant and Royal Navies.4The language spoken by most of the settlers is Sylheti which does not have a (widely used) written form.

Bengali speaking pupils in London (46,681 including Sylheti and all other varieties) are concentrated broadly in an area immediately north of the river Thames in London. From Westminster in the west to Barking & Dagenham in the east, there are nine boroughs with more than 1,000 Bengali speakers each and which together account for over 80% of the Bengali-speaking community. Tower Hamlets is home for just over 43% of the London Bengali community, although this figure represents a decrease when compared to the borough‟s 47% share in 1998/99.

However when we analyse the data on ethnic origin –„Bangladeshi‟ with the data on language – „Bengali‟ or Sylheti‟ in Tower Hamlets an interesting pattern is revealed. The borough council‟s analysis of the school census data shows that the number of Tower Hamlets pupils who are of Bangladeshi origin has increased in the last decade than the proportion of the Bangladeshi community describing itself as Bengali-speaking is declining.5

london map

This raises some important questions for languages policy. For example, while the first generation of Bangladeshi settlers (mostly post World War II) may not have spoken fluent English the third and fourth generations generally do. There are still some people especially first generation migrants who do not speak English fluently. A survey of Bangladeshi adults in the 1990s found that only 75% of Bangladeshi men and 40% of Bangladeshi women said they spoke English fluently6. On the other hand, from the evidence about school children it appears that many younger people will not be able to interpret for them because they don‟t speak Bengali/Sylheti. This has direct implications for the use of informal and ad hoc interpreters. The problem is compounded if mediating communication is seen not simply a matter of linguistic competence but cultural competence and also ability mediating power relationships.7

3. Methodology

One to one interviews were held with members of the Bengali speaking community in East London. They all were users of the NHS but one group was ad hoc interpreters while the other one was patients.

The interview questions were designed in a way to elicit in the first group whether or not they have done any interpreting on an ad hoc basis - how they felt about it and if they had any difficulties. The second group was asked whether they used professional interpreters, Link Workers, community workers or bilingual advocates or ad hoc interpreters or family members to access NHS services

3. Settings

Interviews took place in various locations focusing on highly populated Bengali speaking community. However, to widen the sample group we also approached members of the Bengali speaking community opportunistically outside GP surgeries and health centres. Great care was taken to respect patient confidentiality in every location where we interviewed them.

The interview questions are presented in Appendix 1.

The inclusion of the Bengali speaking community from beyond the practices that had agreed to take part did not, we believe materially affect the setting of this project. The same questionnaires were given out and same questions were asked as if they were waiting in the GP surgery.

Once a contact was established, each practice was visited. The sample questionnaire was intended to be used as guideline. It was given out to participants. Almost all participants preferred for the researcher to fill it on their behalf, as some participants were not able to read or write.

47% of the participants were contacted through social network of the researcher and in Health centre waiting area with the permission of the practice managers or a senior member of staff. 30% were contacted through attendance at a Bengali health awareness event. It was a full day event organised by a community group – Women‟s Health and Family Services and a University - Kings College, London. They both either were ad hoc interpreters or patients. 23% were contacted by attending an immunisation event which was organised at a Health Centre. Only 4% of people invited to take part, declined to do so.

3. Results

FOR PATIENTS – (n=50)

Have you needed an interpreter or advocate in order to use an NHS service?

46 - said YES 4 - said NO

29 – Female 21 – Male

Who and at which frequency:

Who have you used In the last week In the last month The last year Ever (but not in the last year) Total
A relative 7 7 11 4 29
Friend 1 3 3 4 11
Neighbour 1 2 7 4 14
Member of NHS staff who is not employed as interpreter/advocate 2 5 6 4 17
Interpreter / advocate provided by the NHS 10 17 14 4 45


What age groups did they come from:

Age Under 11 11 - 16 17/18 19 - 54 55 - 74 75 +
0 6 2 20 13 11


Common comments

Most of the patients said that they needed an interpreter in their interaction with the health (and other public) services as they spoke little or no English and did not have enough confidence to face the health professionals. The majority of the patients who needed someone to interpret for them stated that they used ad hoc interpreters regularly. For most of them, these were their children and other relatives like husbands, sisters or brothers/sisters-in-law. The number of female patients was greater than male patients. They also stated that whether they try to use an interpreter provided from NHS depends on the availability of an interpreter in their GP surgery or hospital. Many also said that if they are very concerned in respect to their health, they would seek out a professional interpreter but if it something less significant, then they would be happy to take their children or relatives. The issue of trust was always in the background of these statements Many of them directly commented that they “felt more comfortable with their children compared to the professional interpreter” and that “I felt safe”. They also relied on their family members to remember information (e.g. dates, symptoms etc) “in case they forgot”. Trust was not only in a social, but also in the linguistic sense – “I feel the professional interpreter cannot translate word for word”, reflecting their expectations as well as dependence on the family member.

FOR INFORMAL AND AD HOC INTERPRETERS – (n=50)

Have you interpreted for your family members, friends or neighbours?

41 – said Yes 9 – said No

17 – Male 33 – Female

For whom and at what frequency?

Who have you used In the last week In the last month The last year Ever (but not in the last year) Total
A relative 14 19 29 4 68
Friend 3 4 9 4 20
Neighbour 7 8 14 4 33


What age groups did they come from:

Age Under 11 11 - 16 17/18 19 - 54 55 - 74 75 +
1 8 9 28 4


Common comments

A large majority of the participants stated that they do ad hoc interpreting regularly to family, friends or neighbours at least once a month but in many cases, once a week. The majority of those were again females aged 19 to 54 years old. However it must be noted that 11-16 years old had also a high number of ad hoc duties to their family and friends. Most of them saw it as their “duty” to do this whenever their elders asked them to, but those of the school age group also resented having to miss school and spend long hours in surgeries or hospitals, especially when there are so many interpreters around.

Some of the most common comments from male and female Bengali young people who were frequently asked to interpret for their relatives are cited below:  (Male) I felt really embarrassed when I was translating for my mum about women problems.  (Female) I felt pressured by my family that I always have to interpret for them.  (Female) I don’t have any medical knowledge at all therefore I find it hard to understand when the professional uses any sorts of medical words. And I don’t have the courage to ask them to explain. Also, often I use the same English word because I don’t know the Bengali word for it.  (Female) Sometime I have to miss school in order to interpret for my mum at hospital.

4. Discussion

More Bengali patients reported using informal or ad hoc interpreters than using paid/professional interpreters and advocates. Four out of every five people more or less randomly contacted had done informal or ad hoc interpreting, mostly for their family members, friends or neighbours.

This is particularly unexpected in Tower Hamlets (where the research was conducted), where the estimated number of Community Link workers, bilingual Advocates, Interpreters and other Language Support Workers officially employed to work in the voluntary or statutory sectors, is estimated to be over 200 (N. Ahmed, personal communication, April 2010).

The context of this on-going demand for informal and ad hoc interpreters is a diminishing potential pool of interpreters. For this reason it is important to look at the skills and attitudes of potential interpreters.

For this reason, the next stage of the project is to run a training course with ad hoc and informal interpreters to improve their cultural and linguistic competences.

Appendix 1

For informal and ad hoc interpreters

Have you interpreted for any of the following?

In the last week In the last month The last year Ever (but not in the last year) Total
A relative
Friend
Neighbour

Personal details

Age Under 11 11 -16 17/18 19 - 54 55 -74 75 +


Sex Male/Female

For patients Have you needed an interpreter or advocate in order to use an NHS service ?
Yes/ No

If yes

Who have you used ... In the last week In the last month The last year Ever (but not in the last year) Total
A relative
Friend
Neighbour
Member of NHS staff who is not employed as interpreter/advocate
Interpreter/advocate provided by the NHS


Personal details

Age Under 11 11 -16 17/18 19 - 54 55 -74 75 +


Sex Male/Female

Notes:
1 Eversley J et al (In Press) Language Capital – Mapping the languages of London’s school children, CILT/IoE
2 Turkish is spoken by little under 17,000 pupils
3 DCLG (2009) The Bangladeshi Muslim Community in England Understanding Muslim Ethnic Communities. DCLG London
4 Ullah, AA and Eversley J (2010) Bengalis in London’s East End. Swadhinata Trust.
5 LBTH EMA Service (2008) Key Ethnic Minority Achievement Statistics and Information. LBTH & Baker, P & Eversley, J, Eds, (2000). Multilingual Capital. The Languages of London's Schoolchildren and their Relevance to Economic, Social and Educational Policies London: Battlebridge Publications.
6 PSI Fourth Survey of Ethnic Minorities reported in Tackey, ND, Casebourne J et al (2006) Barriers to employment for Pakistanis and Bangladeshis in Britain Department for Work and Pensions Research Report No 360 http://research.dwp.gov.uk/asd/asd5/rports2005-2006/rrep360.pdf
7 Baylav, A (2003) ‘Issues of Language Provision in Health Care Services’, pp 69-76 in Tribe R & Raval, Heds.,. Working with Interpreters in Mental Health Hove & New York: Brunner Routledge.