The challenge of communication in interpreted consultations in diabetes care: a mixed methods study

INTRODUCTION

In 2012, diabetes was estimated to affect 3.1 million individuals in the UK and to consume 4% of the NHS budget.1 Individuals from minority ethnic communities are five times more likely than others to have type 2 diabetes.2 In east London, where this study was carried out, the prevalence of type 2 diabetes has been found to be 3.5% for white individuals, 11% for South Asian individuals, and 8% for black individuals.3

National audits of care show geographical variability in carrying out nine crucial tests at annual diabetes review:4,5 measurements of weight, blood pressure, smoking status, glycosylated haemoglobin (HbA1c), urinary albumin, serum creatinine, and cholesterol, and secondary damage to the eyes and feet. There is also variability across ethnic groups. Among those with type 2 diabetes, white patients have been shown to be more likely than other ethnic groups to have completed all of these care processes.5 Encouraging self-management of diabetes is an important priority for care providers, and an important part of diabetes review is to inform and motivate patients in this task.6

Although community leaders may disagree,7 some evidence suggests poorer awareness of diabetes and its complications in minority ethnic communities.8 In one study, individuals of Pakistani and South Asian origin living in Edinburgh were found to be more likely to blame their external environment than themselves for their diabetes.9 Chronic kidney disease in black and South Asian patients with diabetes is more severe than in white patients, whose glycaemic control is also better.3

Dissatisfaction with diabetes care among patients and others of Bangladeshi origin has been found in studies in Bradford,10 Cardiff,11 and east London.7 Frustration by healthcare providers is also reported in these studies. Socioeconomic and educational differences that are associated with ethnicity may explain some of the differences in experiences of care, but it is clear that much of this difficulty stems from communication problems where different languages are involved. Responders in the study of east London specifically cite difficulties experienced in consultations involving interpreters,7 and there is some evidence that patients’ presentation of themselves as knowledgeable, morally responsible individuals is more difficult when patients and providers do not share the same language.12–14

With over 300 languages spoken in London alone and an estimated 300 000 individuals in the UK without functional English to permit communication with a health service provider,8 it is unsurprising that provision of professional interpreter services in the NHS is both common and costly.16 Yet there have been no significant published studies involving direct observation of interpreted consultations in the UK, although some work of this sort has been done on consultations with UK patients for whom English is a second language.17,18

This contrasts with research from the US and elsewhere, which provides some evidence about common difficulties in communicating through interpreters. Much of this work involves Hispanic speakers in the US, the relevance of which for other settings and cultures is unknown. Such studies have found that interpreted consultations, when compared with same-language encounters, involve less affective talk, less discussion of the patient’s personal circumstances or ‘lifeworlds’, and less investigation by providers of patients’ knowledge or health beliefs.19–21 Patients in interpreted consultations are often less active, asking fewer questions,19,21,22 and interpreters have sometimes been found to either answer patients’ questions themselves without translating them, or fail to translate or answer them.12,22 Errors, omissions, misunderstandings, and inaccuracies in translation have been documented, particularly where informal rather than professional interpreters are used.12,13,19,23,24 Health service providers commonly do not address the patient directly, instead address the interpreter,25 and professional interpreters commonly take on the role of ‘co-diagnosticians’, aligning themselves with the perspectives of healthcare providers rather than patients.12,20,26 Providing extra time for interpreted consultations, splitting talk up so that it is delivered in smaller chunks, and frequently checking understanding has been recommended.27,28

This article reports data from the first study in the UK involving direct observation of interpreted consultations, comparing these with same-language consultations. The research studied routine review consultations for diabetes care, largely carried out by nurses in primary care settings, occurring in east London where a significant proportion of the population (and of those with diabetes) is of Bangladeshi origin. Content analysis of video-recorded consultations is used to provide insight into the challenges they present and the relevance of recommendations on how to work with interpreters in a UK context.27,28

RESULTS

Table 2 shows that, although there was no significant difference in the time taken by interpreted and same-language consultations, patients who spoke English produced 3.6 times the number of words produced by patients in interpreted consultations.

Table 3 demonstrates that, while patients’ misunderstanding and their attempts to check understanding were not significantly different across the two groups, patients in same-language consultations were more likely to produce utterances that included questions or that involved discussion of health education or of their own motivation to engage in health-related behaviour, and to participate in praise for health-related actions or knowledge. With the exception of employment, all of the patient world ‘patworld’ codes (Table 1) more frequently applied to patient speech in same-language consultations, with more humorous moments and discussions of feelings and of ‘lifeworld’ topics, as defined by the researchers (Table 1). A number of diabetes-related clinical topics were discussed more in same-language consultations. Patients in interpreted consultations devoted less speech to medical issues unrelated to diabetes (‘medical other’) and there was less talk about patients’ own ideas about the workings of their bodies or of health and illness (‘epistemic’), as well as less patient involvement in evaluating or informing about diabetes-related clinical parameters (patient clinical parameters) (Table 1).

Table 4 shows that providers were more likely to produce utterances containing humour and to talk about feelings with their English-language patients, so that overall their talk about ‘patient world’ was significantly less common in interpreted consultations.

The findings about humour are supported in the Wordsmith analysis shown in Table 5, which also shows that the usage of personal pronouns was different in interpreted consultations. The higher usage of the third person by providers in interpreted consultations is largely because they address the patient through the interpreter rather than directly. Thus, a concordance analysis showed that ‘does he’ is the most common two-word phrase associated with providers’ usage of ‘he’ in these consultations (33 times), and the most common verbs occurring before ‘him’ in provider talk in these consultations are ‘see’, ‘ask’, ‘give’, ‘tell’, and ‘help’. Patients are also more likely to use the third person in interpreted consultations.

Tables 3 and 4 also show that substantial amounts of both provider and patient talk contained passages either that were not translated by the interpreter or where the meaning of what was said was changed. Looking at this in terms of the proportion of speech passages (‘utterances’) involved, 307/920 (33.4%) utterances made by patients in the 12 interpreted consultations contained some talk that was not translated, and 674/1644 (41.0%) utterances from the providers contained some talk that was not translated. Interpreters also quite commonly spoke about topics that did not involve an attempted or actual translation of what another speaker had said (‘other than translated’ speech); 685/2057 (33.3%) utterances by interpreters involved this kind of material.

DISCUSSION