All patients have the right to equal access to health care that meets their individual needs. The Swedish Health and Medical Services Act (1982:763) states that the objective of health care is good health and care on equal terms for the whole population. Section 2 (b) states that the patient should be given individually tailored information on 1. His state of health 2. The methods of examination, care, and treatment that exist.
Between the end of the Second World War and the 1960s, Sweden had a large influx of labour immigrants. Since the 1980s, immigration has been dominated by refugees and/or individuals with family members in Sweden. Sweden is a multicultural society, with 19% of its population in 2011 having a foreign background [
An assessment of primary care services conducted in London by Campbell et al. [
Five key predictors of culture-related communication problems in medical consultations were identified in a review by Schouten and Meeuwesen [
Conversation analytic studies have illuminated interactions between healthcare professionals and patients. Pilnick et al. [
Using a questionnaire about triangular meetings between immigrant patients, interpreters, and GPs in primary health care in Stockholm, we previously found that 63% of patients were satisfied with their consultations [
In order to complement the existing knowledge and possible theories about reasons for communication problems in the triangular meeting, we decided to explore more deeply what happens during the meeting between the three participants. A
The objectives of this study were to gain insights into participants’ perceptions of and reflections on consultations by means of in-depth interviews with immigrant patients, interpreters, and general practitioners and to perform an in-depth qualitative analysis of the interviews.
Participants in the following three categories were selected on the basis of participation in the same consultation: immigrant patients from Chile, Turkey, and Iran, their interpreters, and GPs at five different primary health care centres (PHCCs) in Stockholm. The interviews took place between 2004 and 2010 one-two weeks after the consultation. The participants received both verbal and written information and provided informed consent. Professional interpreters who were not included in this study were booked for the patients’ interviews. A total of 29 individuals—10 patients, 9 interpreters, and 10 GPs—participated in a total of 30 face-to-face interviews. One interpreter was interviewed twice. Because the content of the two interviews with this interpreter differed, both were included in the analysis. Seven GPs were from Sweden and the rest were born abroad. All GPs had a lot of experience of working in PHCCs with high proportions of immigrant patients. Three of the interpreters spoke Spanish as their mother tongue, three Persian, and three Turkish. All had worked as interpreters for many years—in six cases more than 10 years—except for one, who had only worked for 2 months. Seven of the interpreters were authorised (public authority exercised by “Kammarkollegiet,” Legal Financial and Administrative Services Agency). The participants’ characteristics are shown in Table
Characteristics of the patients, interpreters and GPs.
Participants ( |
Age | Gender | Country of origin | Length of residency in Sweden | Mother tongue |
---|---|---|---|---|---|
<65 yrs old: |
Male: |
Chile: |
Spanish | ||
Patients ( |
>65 yrs old: |
Female: |
Iran: |
4–33 years | Persian |
Turkey: |
Turkish | ||||
| |||||
Age | Gender | Country of origin | Length in profession | Mother tongue | |
| |||||
<50 yrs old: |
Male: |
Syria: |
Spanish | ||
>50 yrs old: |
Female: |
Iran: |
<1–28 years | Persian | |
Interpreters ( |
Turkey: |
Turkish | |||
Uruguay: |
|||||
Sweden: |
|||||
| |||||
<50 yrs old: |
Male: |
Iran: |
Persian | ||
GPs ( |
>50 yrs old: |
Female: |
Equatorial Guinea: |
Many years: |
Icelandic |
Iceland: |
Swedish | ||||
Sweden: |
In-depth interviews took place at five different PHCCs in Stockholm County and lasted 45–60 minutes. The interviews were led by one of the researchers (EW) using an interview guide (see Appendix). Professional interpreters who were not included in this study were booked for the patient interviews. They started with open questions encouraging the participants to elaborate on their experiences and reflections. The interviews were tape-recorded and transcribed verbatim. Each participant was sent a written copy that had been translated into his/her native language by a professional interpreter. The participants were asked to comment on and confirm the accuracy of the content and to return their copies to the researcher (EW). Three patients returned their copies, one with comments in his own language, which were subsequently translated into Swedish. Six of the interpreters returned their copies, three with comments. Six of the GPs returned their copies, three with comments. The comments were reviewed, but did not contribute any additional information to the interview content.
Two of the researchers (EW and NSS) used content analysis [
In content analysis, themes are created by condensation. Condensation involves summarising what appears in the text using a description that is as similar to the text as possible. Next, an interpretation of the underlying meaning of the condensed text is provided. Finally, the underlying meanings are linked together as subthemes and themes. An example of the analysis process is shown in Table
Content analysis: examples of a meaning unit, a condensed meaning unit, a subtheme, and a theme from the content analysis of patient’s experiences and reflections pertaining to a consultation.
Meaning unit |
Condensed meaning unit | Condensed meaning unit |
Subtheme |
Theme |
---|---|---|---|---|
Description similar to the text | Interpretation of the underlying meaning | |||
|
The patient says that she wants to have not only an exact verbal translation, but also a translation with feelings, emotions, and experiences. | The patient has a need for interpretation with words, feelings, and experiences. | Need for verbal and emotional interpretation | Professional interpretation |
Our analysis generated six themes common to the three groups (patients, interpreters, and GPs), which we categorised into two subject areas: the interpretation process (
The interpretation process consisted of two different components: linguistic and cultural interpretations. Linguistic interpretation includes translation between two languages, as well as explicit explanation of medical terms, for example “migraine.” In cultural interpretation, the patient’s cultural perspective is taken into account. The interpreter’s personality and own strategies appeared to be important factors in the interpretation process in the means of interpreting and means of informing.
The majority of the patients felt that having a professional interpreter was important for a good patient-GP relationship, with the interpreter’s role being to establish trust and create a good atmosphere. It was important for the patient to feel free to express exactly what he or she wanted to say.
Some patients expressed the importance of adjusting information to their culture and level of knowledge about body functions. They also stressed the importance of translating medical terms into everyday language.
According to the participants, a successful meeting between the patient and the GP during the consultation requires adapting to the individual patient. Other important factors were consultation time, the patient’s feelings, and the role of family members.
A feeling of frustration was expressed by the majority of the patients. One of them said.
Two interpreters commented that the way to provide information to the patient must be adapted to the patient’s level of knowledge about the body, even for written information. This is the responsibility of the interpreter, the GP, or collaboration between them.
One interpreter expressed the need to intervene when the GP is unaware of the patient’s dissatisfaction or fear.
One GP commented that it is important to be professional, to show respect and understanding for the patient’s earlier experiences and autonomy, which sometimes may lead to compromises. Another GP commented that it is important in every consultation to show respect for the patient without any prejudices about their background.
Another GP commented that even when the patient has no or little command of Swedish, direct communication improves contact, making consultations more active and revealing.
The participants’ different perspectives concerning the themes are illustrated in Table
Participants’ different perspectives concerning the themes.
Theme | Patients | Interpreters | GPs |
---|---|---|---|
The interpretation process | |||
Means of interpreting | (i) Establish trust |
(i) Translate every word precisely |
(i) Different techniques |
Means of informing | (i) Adjust info to culture and level of knowledge |
(i) Tell a little |
(i) Adjust your way of communication |
| |||
The meeting itself | |||
Individual tailored |
(i) Kind response |
(i) Individual approach |
(i) Mutual understanding |
Consultation time | (i) Tell everything |
(i) Never sufficient |
(i) Need of longer time |
The patient’s feelings | (i) Frustration not |
(i) Stress |
(i) |
The role of family members | (i) Give security |
(i) Interfere |
(i) Not to divulge confidential info |
Variation in the quality of the interpretation and the relationship between the patient and the GP could affect the outcome, as illustrated in Table
Effects of the interpretation process and the quality of the patient-GP relationship on the success of a consultation.
(1) | ||
Good interpretation (P + IP)? | Yes* | Successful |
Good patient-GP relationship (P + GP)? | Yes** | consultation |
| ||
(2) | ||
Good interpretation (P + IP)? | No*** | Less successful |
Good patient-GP relationship (P + GP)? | Yes | consultation |
| ||
(3) | ||
Good interpretation (P + IP)? | Yes | Less successful |
Good patient-GP relationship (P + GP)? | No**** | consultation |
| ||
(4) | ||
Good interpretation (P + IP)? | No***** | Unsuccessful |
Good patient-GP relationship (P + GP)? | No****** | consultation |
A successful consultation embraces good interpretation
*GP10: “A good interpreter who has extensive experience translates quickly; uses shorter sentences, not very long explanations … without the medical content being compromised.”
**IP7: “… the doctor’s trust towards his patients and patients’ confidence in their doctor … it requires a great deal of patience on both sides….”
***P4: “It has not gone well the times we have had an interpreter. The interpreter could not translate into Swedish.”
****P4: “If I see that the doctor does not understand, then I say that I can see that you do not understand…in that case I have to go to another doctor….”
*****IP7: “…To give a fast interpretation and perhaps over-interpret…due to be flexibility… a tendency to make what patient says better or to over-interpret it….”
******GP5: “… but is it the case when the interpretation is not working you lose the touch….”
In this study, our main findings have indicated that the dynamics between the three participants during a consultation influence the relationship between the GP and the patient and therefore also mutual understanding. This is in congruence with a study by van Wieringen et al. [
Even though the three groups of participants had themes in common, they sometimes had different perspectives on these themes. Concerning means of interpreting, patients and GPs had the same or similar perspectives. All three groups of informants had similar perspectives on the means of informing. Also, when looking at the “individual tailored approach,” we found similar perspectives, except for the interpreters, who stressed that “medical authority” was important for some patients. All three groups commented that establishing good contact and a good relationship, as well as exchanging information between the patient and his or her GP through an interpreter, is often time consuming. Most interpreters commented that patients complained about consultation times. The patients expressed a sense of frustration during the consultation, while interpreters expressed stress and uncertainty. The GPs reported that some patients had felt offended about what had been said and pointed out patients’ expectations of having a professional interpreter without any judging. Patients and GPs see positive sides to the role of family members, whereas interpreters see it as a threat and as negative. GPs have both positive and negative views about it.
Baker et al. [
The meaning of “professional interpreters” varies from one country to another. This variation has implications for everyday encounters for which interpreters are booked. Different countries have different skill requirements for examinations and certifications administered by a knowledgeable authority (The Legal, Financial and Administrative Services Agency in Sweden).
In our study some patients wanted their feelings to be interpreted, but for a professional well-trained interpreter who has been taught not to interpret anything other than what is said, it may be against his/her ethics to interpret unsaid emotions. Sometimes the patient feels uncertain about the interpreter’s professional confidentiality, despite information about it. It is important for the patient’s feelings of trust and confidentiality to listen to the patients’ wishes concerning the interpreter’s behaviour during communication, including respect and a professional neutral attitude [
To use a professional interpreter is also important for enhancing the patient-care provider relationship and patient centeredness [
The patient is conscious and aware of interactions between the participants during the consultation and the smallest details of how the communication between the participants’ works can have a sizeable impact on the eventual outcomes [
Awareness of the patient’s cultural views was not deemed important by our participants, as it was in a previous study by Harmsen et al. [
When introducing a third person to two-person communication, it takes time to establish trust. Sufficient consultation time is necessary to obtain a correct and complete medical history and to adopt a patient-centred approach in which decision making is shared.
Strength of this study is the opportunity we had to gain insights into the perspectives of all three groups of participants in the consultations by using triangulation and to give a description of these perspectives. We received a richness of data, where the divergence and convergence of the findings, illustrated with quotations from the three views, are a contribution to a deeper understanding of communication problems. We have found a few similar studies in the literature. The validity of the study is good, since the study has been accustomed to the common different stages in a qualitative research interview and the use of interpreters trained in the research field [
A limitation is that there are few patients of three different countries involved in the study. The subjectivity of patients’ responses is prone to be influenced by the characteristics of each patient. Nevertheless, each interview is unique and the findings are contextual. Since it is a qualitative study, the findings cannot be generalized, but may be transferred to other contexts with similar characteristics [
This paper has highlighted feelings of frustration and insecurity when interpretation and relationships are suboptimal. Strategies for reaching a successful consultation may therefore be needed for all three participants during consultations. To transform the triangular meeting between an immigrant patient, an interpreter, and a GP from an encounter to a real meeting, this study has indicated that there is a need for a professional interpreter, for the GP to use a patient-tailored approach and to have sufficient consultation time. Use of professional interpreters is recommended, as is developing cultural competence. Further research in this field is needed in order to obtain a deeper understanding of the triangular meeting.
Could you tell us about your experiences about visiting a GP in primary health care with an interpreter? (Please give examples. Have you been understood? Have you been able to say what you wanted? Have you received help? Were there any problems, and if so, have they been solved?) This is hopefully followed by a story where the interview guide will serve as a background and as a memory list to check that relevant facts and experiences are included in the story.
Could you tell us about your experiences to interpret immigrant patients from Chile, Turkey and Iran as they are visiting a GP in primary health care? (Please give examples. Do you think the GP understood the patients’ problems and the cultural background? Has the patient been helped? Were there any problems, and if so, have they been solved?) This is hopefully followed by a story where the interview guide will serve as a background and as a memory list to check that relevant facts and experiences are included in the story.
Could you tell us about your experiences to have immigrant patients from Chile, Turkey, and Iran on medical consultations and cooperate with the interpreter? (Please give examples. Do you think the patient felt that he/she has been understood and helped? Do you know the patient’s cultural background and its influence? Were there any problems, and if so, have they been solved?) This is hopefully followed by a story where the interview guide will serve as a background and as a memory list to check that relevant facts and experiences are included in the story.
Study conception and design were conducted by J. Sundquist and E. Wiking. Data collection was done by E. Wiking. Analysis, drafting of manuscript, and critical revisions were done by E. Wiking and N. Saleh-Stattin. Critical revision was done by J. Sundquist. Supervision was the mission of N. Saleh-Stattin and J. Sundquist.
The authors declare that they have no conflict of interests.
The authors are grateful to the participating patients, interpreters, and GPs for their involvement. Funding was obtained from the Swedish Research Council and the Swedish Council for Working Life and Social Research. Ethical approval was obtained from the Research Ethics Committee at Karolinska Institutet. They confirm that all participant identifiers have been removed or disguised so the participants described are not identifiable and cannot be identified through the details of the story.