Review
Working with interpreters in health care: A systematic review and meta-ethnography of qualitative studies

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Abstract

Objective

To identify relational issues involved in working with interpreters in healthcare settings and to make recommendations for future research.

Methods

A systematic literature search in French and English was conducted. The matrix method and a meta-ethnographic analysis were used to organize and synthesize the data.

Results

Three themes emerged. Interpretersroles: Interpreters fill a wide variety of roles. Based on Habermas's concepts, these roles vary between agent of the Lifeworld and agent of the System. This diversity and oscillation are sources of both tension and relational opportunities. Difficulties: The difficulties encountered by practitioners, interpreters and patients are related to issues of trust, control and power. There is a clear need for balance between the three, and institutional recognition of interpreters’ roles is crucial. Communication characteristics: Non-literal translation appears to be a prerequisite for effective and accurate communication.

Conclusion

The recognition of community interpreting as a profession would appear to be the next step. Without this recognition, it is unlikely that communication difficulties will be resolved.

Practice implications

The healthcare (and scientific) community must pay more attention to the complex nature of interpreted interactions. Researchers need to investigate how relational issues in interpreted interactions affect patient care and health.

Introduction

The combination of globalization and the different waves of immigration to Western countries has resulted in an increasingly socio-culturally diverse population. Since many migrants do not speak the official language of their host country, this linguistic gap has been shown to be one of the major causes of health disparities [1]. The literature reports inappropriate diagnosis [2], poorer adherence to treatment [3] and follow-up [4], [5], more medication complications [6], longer hospitalizations [7] and decreased patient satisfaction [8]. One way to overcome these problems is to work with interpreters.

Ever since this issue came to the attention of the scientific community in the 1980s, interest in it has continued to grow. When reviews were conducted all concluded that working with interpreters was essential to reducing health disparities and improving quality of care; medical interpreters [9], [10], bilingual physicians and staff [9], [11], and bi/multilingual nurses from various cultural backgrounds experienced in transcultural nursing [10] were called on to act as interpreters. Many of the studies from which these reviews drew their conclusions, however, did not differentiate between the effects of different types of interpreters on improved quality of care. In response, Karliner et al. [12] and Bauer and Alegria [13] questioned the specific impact of professional versus non-professional interpreters (which we call “ad hoc” interpreters) on clinical and psychiatric care. Both studies concluded that working with professional interpreters improved quality of care. Interpretation is more than just a technique to make health service more accessible to patients who speak a foreign language, however. As Tribe and Lane [14] mentioned in their review and guidelines on working with interpreters in mental health, interpretation also offers clinicians an opportunity to expand their knowledge and understanding of a range of clinical perspectives. Investigating the relational issues involved in providing interpretation during medical consultations appears to be the next step in improving quality of care.

Although qualitative and quantitative studies have long been shown to be complementary [15], the systematic reviews mentioned above [9], [12], [13] seem to have neglected their respective contributions. The results of the selected studies are treated similarly, as if both types of research generated similar types of results.

The aim of our study was to conduct a systematic review and meta-ethnography [16], [17] of qualitative studies on interpreting in healthcare settings to better understand the relational issues involved in interpreted consultations with different types of interpreters, and to make recommendations for future research.

Habermas's distinction between the System and the Lifeworld was used as an interpretative framework to organize and give meaning to the results. These concepts have already been used profitably to understand communication in healthcare settings [18], [19], [20], and especially in interpreted consultations [21], [22]. The System, which comprises the economy and the state, is characterized by strategic action (oriented toward efficiency and success). The Lifeworld, which comprises the private and public spheres, is characterized by communicative action (oriented toward making collective sense of a situation in order to come to a consensual understanding on the course of action to take) [23].

Section snippets

Data sources

We conducted a systematic qualitative literature search for publications from the inception of each database to June 2010 in PsycInfo, EBSCO Medline, Current Contents, Web of Science, CSA Linguistics and Language Behavior Abstracts, SCA Sociological Abstracts and the Cochrane Library, with “interpreter*” and “health” as key words. After deletion of duplicates, our search produced 823 references (Appendix A).

Inclusion/exclusion criteria

We included all qualitative peer-reviewed publications in French and/or English. We

Quality of studies

We noted great variability in the way authors reported their findings (see Appendix C for details). Approximately half of the papers provide no information on participants’ socio-demographic characteristics (but numbers are rarely omitted). In total, 25 studies focus on professional interpreters only, 11 on ad hoc interpreters only, while more recent studies (n = 13) take both types into greater account. Seventeen of the studies do not specify the type of interpreters, but five provide sufficient

Contexts of publication

A distinct profile emerged when selected studies were considered based on country of publication. In the case of the three most productive countries, the increase in publication is clearly connected to their political situations. In the US, the increase in the number of publications coincided with Executive Order 13166, signed in August 2000 by President Clinton, requiring all federal agencies to comply with Title VI of the 1964 Civil Rights Act [91], which stipulates that the health system

Conflict of interest

The authors are not aware of any conflict of interest with regard to this manuscript.

Acknowledgements

We wish to thank Alexandra Boilard, Isabelle Boivin, Émilie Charest, Jessica Garant, Guillaume Lafontaine, Stéphanie Landry, Évelyne Marquis-Pelletier, Thomas Michaud Labonté and Myriam Sylvain for their invaluable assistance in the selection and abstraction process. We also thank Richard Dufour, librarian at Laval University, for his contribution to our literature search.

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