Interpreting culture in health care

Language and culture have always been intertwined. Researchers have long studied the role of culture in perceiving and translating reality and how this perception is communicated through language.

In the field of medical interpreting, interpreters find themselves not only interpreting for individuals who do not share the same language, but who also do not share the same culture or the same perception of the etiology of health care. At the technical level, communication is explicit and the negotiation of meaning is minimal. However, at the semantic level, cross-cultural communication in health care is not explicit and negotiation of meaning is left to interpretation.

Quality health care services depend on accurate communication between a patient or a caregiver and a health care provider. Most health care encounters involve communicative events between two people. Providers depend on communication to understand the symptoms that will lead to an eventual diagnosis. Without it, a doctor might not clearly understand the symptoms that will be used to diagnose the patient, and the patient might not clearly understand the best treatment option to select or the risks of a particular procedure. Studies such as “Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters” have shown that errors in communication can therefore lead to negative health care outcomes and a degree of liability to the health care provider and organization.

When a health care provider and a patient do not share the same language, then a third party might be requested. When a patient and provider communicate with the assistance of a third party, this is called a triadic communicative event. While many bilingual individuals are called on to attempt to facilitate communication, professional interpreters are the individuals who are trained to undertake this intellectually challenging and highly technical task. They listen in one language what the provider or patient are stating and then interpret the meaning of the message, without omitting, adding or distorting the message into the other speaker’s language. Because different languages utilize different terms or expressions, these are not word-for-word translations, as one might suppose. If a concept does not exist in the other language, how will a medical interpreter interpret or explain it to the other party? There are two standards of practice on the subject, and there has been some confusion and misinformation in the field as to what these standards say.


IMIA Standards

The International Medical Interpreters Association (IMIA) Medical Interpreting Standards of Practice are founded on the premise that an interpreter’s primary task is interpretation, that is, the transformation of a message expressed in a source language into its equivalent in a target language, so that the interpreted message has the potential for eliciting the same response in the listener as the original message.

The IMIA standards were developed in 1992 by the Massachusetts Medical Interpreting Association and The Development Center, using the DACUM process, a well-known and validated method of occupational analysis for professional and technical jobs. It was developed with the intention of being the grounding work needed for medical interpreter certification. It was adopted on a national level in the United States at the 4th National Working Group conference in Seattle, Washington, May 17-19, 1998. The IMIA standards have since been translated and used internationally in Spanish, Italian, Hebrew, Japanese and Portuguese. The IMIA Medical Interpreting Standards of Practice are organized into three major task areas: interpretation, cultural interface and ethical behavior.

To quote from the standards, “If all that the provider and patient need to achieve the goals of the clinical encounter is this linguistic conversion, then simply providing such a conversion fulfills the interpreter’s role. The standards, however, go beyond the skills of conversion and recognize the complexities of interpretation and the clinical interview. The medical encounter is a highly interactive process in which the provider uses language (the provider’s and the patient’s) as a powerful tool to understand, evaluate, and diagnose symptoms (Woloshin et al., 1995) and to mutually inform and instruct. The interpreter, therefore, cannot simply be a ‘black box converter’ but must know how to engage both provider and patient effectively and efficiently in accessing the nuances and hidden socio-cultural assumptions embedded in each other’s language, which could lead to dangerous consequences if left unexplored” (pg. 12).

The IMIA standards explore the cultural interface component of the medical or health care interpreter’s work in detail. Based on the fact that meaning is rooted in culturally based beliefs, it proposes that the interpreter needs to understand the culturally based meanings in order to interpret accurately. It also proposes that the interpreter understand beliefs that affect the presentation of illness, which varies from culture to culture. Perceptions of illness, wellness or treatment can vary greatly in different cultures and can be the cause of miscommunication between a health care provider and a patient who do not share the same culture and perceptions. In these situations literal interpretations do not convey the meaning and therefore are inaccurate. In such cases the interpreter may have to articulate hidden assumptions or unstated propositions contained in the discourse. IMIA proposes that the role of the interpreter is not to explain culture as a cultural anthropologist might, but to assist both parties to uncover these hidden assumptions in order to enable understanding.

The IMIA standards address the common dilemma of the interpreter when a speaker uses “untranslatable” terms or expressions. These are words or expressions that describe words, expressions or even concepts that do not exist in the target language. To get the concept across, the interpreter may have to work with the parties to find ways to transmit the essential meaning of the concept.

The IMIA standards pronounce that the task of the interpreter is to identify these occasions, and while they should not “give the answer,” they should help the parties investigate the cultural issue that is creating the challenge in interpretation.

The IMIA standards make an important observation: that with every situation and person interacting, interpreters cannot assume or predict what an individual believes or practices. They should hypothesize possibilities, and not offer statements before they are verified.

The cultural interface component requires interpreters to observe standard B-1, which is to use “culturally appropriate behavior” with each party. This requires the interpreter to observe the rules of etiquette and/or institutional norms, and adjust his or her behavior to observe such rules of cultural etiquette. There are other responsibilities that the medical interpreter needs to recognize. Standard B-2 requires the interpreter to recognize and address instances that require intercultural inquiry to ensure accurate and complete understanding. Interpreters should pay “attention to verbal and nonverbal cues that may indicate implicit cultural content or culturally based miscommunication,” meaning responses that may not fit with the message being relayed. Interpreters should watch for displays of discomfort or distress when certain topics are brought up. They should also assess “the urgency/centrality of the issue, at that point in time in that particular exchange, to the goals and outcomes of the encounter,” as well as the best method to raise the issue. Standard B-2 outlines that an interpreter “interjects and makes explicit to both parties what the problem might be,” and “prompts the provider and patient to search for clarity.” Additionally, an interpreter should share cultural information with both parties that may be relevant and may help clarify the problem, for example by saying “It’s possible this is what is happening, because often people from . . . believe that . . .” Where untranslateable terms come up, the interpreter should assist the speaker “in developing an explanation that can be understood by the listener.”

As described, while the IMIA standards of practice give ample information about the specifics of a medical interpreter’s work where it relates to cultural issues, they never state that medical interpreters are to act as cultural brokers or mediators. It seems that in these standards, the key issue is accurate communication, which requires complete understanding. When and only when implicit cultural content may cause miscommunication, is the interpreter directed to ensure that a literal interpretation, or language alone is not the cause for misunderstanding. However, it is important to note that some in the field will argue that patients and providers who share a language and not a culture might not benefit from having an interpreter to act as a culture interface. Nevertheless, when an interpreter is present, he or she has an ethical obligation to interpret everything accurately, and this simply cannot be accomplished without an occasional intervention to clarify a cultural concept that is being communicated in words that are not going to be understood by the other party.

The NSGCIS standards

The National Standard Guide for Community Interpreting Services (NSGCIS) in Canada takes a somewhat different approach on interpreting culture. The NSGCIS was created by the Healthcare Interpretation Network (HIN) in 2007 in collaboration with Critical Link Canada, the Language Industry Association of Canada (AILIA) and the Association of Canadian Corporations in Translation and Interpretation.

The creation of the Canadian National Standard was guided by joint efforts from multiple stakeholders across Canada; the committee was composed by 24 members who represented governmental institutions, academia, interpreters, professional orders, nonprofit and private sector organizations.

In early 2010, AILIA announced a new certification program developed for interpreting service providers under the NSGCIS. The NSGCIS is also used as the core document for provider certification in Europe through the Language Industry Certification System.

The goals of the standard are to promote the highest quality of interpreting when adopted for assessment, training, hiring, performance monitoring and possible future professional recognition; to provide clear and consistent definitions of the characteristics and competencies of a qualified community interpreter; and to provide an educational tool or common base of understanding among interpreting parties.

According to Canada’s NSGCIS standard, community interpreting is defined as bidirectional interpreting that takes place in the course of communication among speakers of different languages. The context is the provision of public services such as health care or community services and in settings such as government agencies, community centers, legal settings, educational institutions and social services. It also recognizes that community interpreters work in other settings such as business and industry.

The document encompasses definitions of interpreting terminology, human resources requirements including interpreter’s skills and competencies (interpreting, linguistic, research and technical competence) and how these competencies would be met and demonstrated. It also covers the responsibilities of interpreting parties (clients, interpreting service providers and interpreters), professional standards of practice, core ethical principles and so on. The content of this standard is broader and does not focus on the tasks of the interpreter, and is not specific to medical interpreting. However, since community interpreting does include health care interpreting, it should be addressed.

This standard takes a more rigid stance on interpreting culture as a community interpreter, as seen in the following text from the standard: “Historically interpreters were identified as ‘cultural interpreters’ with a role to bridge ‘cultural misunderstandings’ between service providers and non/limited English speakers. Determining how and when an interpreter should intervene created conflicts for all parties for a variety of reasons. Although cultural differences can exist between individuals who do not share a common language, cultural differences can also exist between individuals who do share a common language. Given the complexity of factors that impact and influence an individual’s culture, acting as a ‘cultural broker/bridge’ goes beyond the scope of an interpreter’s duty, from the perspective of the Language Interpreting Training Program (LITP) Curriculum Development Team. Expecting an interpreter to perform that function, in and of itself, contravenes the ethical principle and standard of practice to remain impartial, and furthermore begs the question of the demonstrated competence of the interpreter to perform that function. Therefore, it should be noted that the LITP Curriculum Development Team recommends that the role of the interpreter focus on the delivery of messages between individuals who do not share a common language rather than ‘cultural differences/nuance’ of the speakers” (NSGCIS, Annex 1, pg. 20).

On the other hand, the same standards, under the section of Role and Responsibilities of Interpreters, states the following responsibility: “The interpreter must be able to understand and convey cultural nuances without assuming the role of advocate or cultural broker” (pg. 18).

Under the principle of accuracy and fidelity which states that “interpreters strive to render all messages in their entirety accurately, as faithfully as possible and to the best of their ability without addition, distortion, omission or embellishment of the meaning,” the standard states in regard to untranslatable terms that the interpreter should retain “English words mixed into the other language, as well as culturally bound terms which have no direct equivalent in English, or which may have more than one meaning. Whenever possible, the interpreter will attempt a translation of that word to provide the listener with an idea of what the word means.” The interpreter should also ask “for repetition, rephrasing, or explanation, if anything is unclear. Upon recognizing that the interpreter has misunderstood the communication, he/she identifies the misunderstanding and requests direction from the parties involved” (page 22).

From a practical perspective, some reasons to move away from the “cultural interpreter” role in Canada include safety for the limited English/French proficiency population (LEP/LFP) while accessing public services. There has also been limited training on the subject — training programs have been limited in time and scope and may not include proper training on cultural interventions, because historically, the average programs varied from 60-100 hours of instruction. Ontario introduced in 2006 a 180-hour training program.

There is also the question of equal access to public services. If the interpreter provides advocacy service to the LEP/LFP, who would provide this service to those immigrants who speak one of the official languages and are navigating the system without interpreters? Finally, culture encompasses several factors, language being only one of them, and sharing the language does not necessarily mean sharing the culture.

Both standards have a different approach as to the issue of interpreting culture. The terms culture broker and cultural mediator are utilized in some studies and trainings, but not in professional standards. There is much controversy in the field as to whether medical interpreters should or should not engage in these expanded roles of culture broker or cultural mediator. There are countries such as Spain, with distinct educational programs for the profession of intercultural mediators. These professionals are trained to moderate and bridge cultural norms in various settings, which is distinct from the primary role of interpreting.


Other approaches

Since the development of the IMIA Medical Interpreting Standards of Practice and National Standard Guide for Community Interpreting Services in Canada, other standards have been developed: notably the American Society for Testing and Materials Standards in 2001, the California Healthcare Interpreters Association Standards in 2002, and the National Council for Interpreting in Health Care Standards in 2005, each with a different perspective and approach that has enriched the understanding of the practice of this profession. We hope that future articles can expound on what the other standards have to say on this topic. There is also a need for further studies that explore the training, advantages, disadvantages, types of cultural interventions and current practices that practitioners are engaging in with regard to interpreting culture in health care.

Medical interpreting is a profession in development. Cultural competency in health care is also a field that has developed in its own right, and is affecting the profession, especially the specialization of medical interpreters, who see themselves as health care professionals who are part of the health care team. The multiple standards of practice in the field represent what needs to be an ongoing, developmental process. There will be variations that are based on country of practice, employment status (contractor vs. hospital employee) and even specialization (generalist or community interpreter who practices occasionally in health care vs. a specialized medical interpreter who only practices in health care). These two standards of practice that apply to medical interpreters showcase some of the variations of approach. Plurality of approaches is expected and is healthy in any profession as it matures.

By setting clear, high standards of performance and practice, a marked increase in the quality of interpreting in the health care arena will follow. This increase in quality will in turn lead to a full recognition of competent, professional and certified medical interpreters, who will be accorded the status and compensation commensurate with the critical nature of their work. This will also create the demand for higher-level training and academic programs that can address the difficult area of interpreting culture.