Medical Interpreting: A Review of the Literature

Developed by J. Moore and L. Swabey
CATIE, College of St. Catherine/NCIEC
DRAFT ~ 2007

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Introduction | Deaf Patient Perspectives | NonDeaf Patient Perspectives | Settings and Types | Challenges and Issues | Interpreting Role | Preparing to Interpret | Summary and Implications | References | Bibliography | Download PDF

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Second-Language Patient Perspectives on Health Care

            Deaf patient perceptions.

Until recent years, sign language interpretation studies specific to health care settings have been relatively scarce. One early study of sign language interpretation during a medical interview detailed an analysis of two certified interpreters’ work in medical interviews between a nurse and a Deaf patient (Cokely, 1982). This study found errors of perception, memory, performance and meaning, and suggested strategies for preventing such errors from occurring. 

Several studies published in health care journals have addressed the experiences of Deaf people in medical situations. Steinberg et al. (2006) used focus group discussions in three U.S. cities to research Deaf people’s health care experiences. Participants said that they communicated best when “medically experienced certified interpreters” were provided, but that these were “infrequently available” (p. 261). Themes that emerged from the focus groups included Deaf patients’ skewed understanding of the health care provider’s instructions and their sense of fear in medical settings. The latter included both a fear of the consequences of miscommunication and a fear of letting health care providers know that the communication was inadequate. Likewise, participants were fearful of changing doctors, as a new doctor might be reluctant to pay interpreters. One reported that a doctor had commented, “The day I have to hire an interpreter is the day I stop having deaf patients” (p. 263). Participants also reported a sense of mistrust, and a feeling that some providers disliked working with Deaf people. They felt frustrated that, in their view, Deaf people received a different level of care than non-deaf people did. The authors of the study concluded that Deaf people who use American Sign Language have much in common with members of other linguistic minority groups: limited access to English communication, infrequent contact with health care providers who know their language and culture, and the frequent necessity of using family and friends as interpreters. Where Deaf and signing health care professionals are available, Deaf patients prefer direct communication over interpreted encounters with non-deaf medical providers.

In another study, Steinberg et al. (2002) interviewed 45 Deaf women on their perceptions of access to health care. These women exhibited a lack of knowledge of health issues, and reported negative health care experiences and insensitive behaviors on the part of providers. They tended to avoid health services because of previous negative experiences. The authors recommended the development of special resource materials, improved prevention strategies targeted specifically to Deaf people, and the development of self-advocacy skills among the Deaf population. In one of the focus groups held in the northeastern United States, a woman explained that having an interpreter available meant the difference between a hysterectomy and a more conservative treatment that would leave her with the ability to bear children (p. 735). The women in these studies also expressed frustration at the difficulty of scheduling interpreting services, and the subsequent delays this caused. Some avoided seeking necessary treatment because of this.

In Boston, group interviews with Deaf and hard of hearing people found providers’ conflicting assumptions about deafness to be a major source of distress in medical encounters (Iezzoni , 2004). Physicians often questioned Deaf patients about the cause of their deafness despite the fact that it was unrelated to the health problem that had brought them to the office. Participants felt that some doctors did not respect their “intelligence, motivation, and desire to understand and participate in their health care” (p. 356). They reported that doctors often did not understand that providing communication access was the responsibility of the health care provider, and that they complained about the costs or inconvenience of obtaining interpreting services. Doctors were also unaware of the need to have an interpreter with experience and knowledge in medical settings. Another issue in the disagreement with providers over interpreting services involved time: Deaf patients typically expressed the need for more time than their clinicians could or would provide (p. 359). Doctors often believed that note writing and lip reading were more effective than they actually are. 

In a study reported in the journal Family Medicine, questionnaires were used to determine Deaf women’s satisfaction with their prenatal care (O’Hearn, 2006). The study found that “Deaf women’s expectations about provision of interpreter services being met or exceeded was significantly associated with overall satisfaction” (p. 712). Deaf women saw a doctor’s willingness to provide an interpreter as a sign of his/her concern for them. The journal article, however, added, “Even providers who recognize a deaf patient’s preference for sign language fail to use interpreter services regularly” . Harmer (1999) noted that health care providers have historically resisted using interpreters, and suggested three reasons: They may not understand the extent of communication barriers; they may see their inability to communicate as a failure on their part; or they may fear cost, violation of patient confidentiality, or the potential of an interpreter to become a witness in a malpractice case (pp. 96-97).

In a British study published in 2000, Ubido et al. found that fewer than one in ten Deaf women understood what the doctor said to them if there was no interpreter present (p. 247). The women believed that non-deaf health care personnel were not able to understand their needs, and that their access to information was reduced. They also expressed anxiety over their experiences in waiting rooms, as they were unable to hear their names being called.

Another study in northwestern England reported that of 98 Deaf adults surveyed, more than half preferred to communicate with their doctors via a professional sign language interpreter, but that only 17% had actually had one provided (Reeves & Kokoruwe, 2005, p. 95). One third reported that they were not sure how well their doctor had managed their case, and did not fully understand their doctor’s advice or what they were to do next. A frequent concern was about medication: inadequate information about it, whether the correct medication had been prescribed, or whether they were using it correctly. The study concluded that “… the single change that would produce the greatest benefit for the largest number of deaf patients is the routine provision of sign language interpreter support for all who desire it” (p. 105).

In addition to communication barriers, it is common for Deaf patients to have limited medical vocabulary with which to communicate with health care providers. Bat-Chava et al. (2005), reporting on HIV/AIDS care and prevention among Deaf and hard of hearing people, found three barriers to Deaf people’s understanding of the disease:  low education level, limited English proficiency, and limited communication with medical providers. Berry and Stewart (2006), in an article advising nurse practitioners on communicating with Deaf patients, stated that most nurse practitioners are unaware that Deaf people struggle with English, an observation that is likely true of most health care providers. Harmer (1999) explained that medical jargon causes problems for Deaf patients because most have limited health care knowledge and because doctors tend to use complex vocabulary and phrases in their explanations, rarely using visual information.  Written materials given to hospital patients require, on average, an 11th grade reading level, and letters from doctors to patients are often written at a 16th grade level. It is generally acknowledged that the average Deaf high school graduate reads at a 4th or 5th grade level. Harmer also reported that, in 1995, a survey indicated that 60% of doctors assumed that 85% of English words could be speech read. 

In addition to difficulties with English, the average Deaf person has fewer opportunities for health education than most non-deaf people have. This results in less initiative to seek answers, less assertiveness, limitations on the types of medical care sought and reduced quality of services received (Harmer, 1999, p. 80). McEwan and Anton-Culver (as cited in Harmer, p. 80) reported that Deaf patients were less likely than other non-English-speaking patients to try to re-explain when providers failed to understand them. In a 1991 survey of Deaf and hard of hearing students, Deaf students exhibited limited knowledge of medical terms, could not properly respond to emergency situations, and were unable to understand prescriptions (p. 82). Similarly, Deaf people may have a poor understanding of the health care system and their own responsibilities for their care (p. 85). In childhood and adolescence, health care encounters are often handled by non-deaf parents, leaving Deaf patients with little awareness of their own medical history or of how the system works.

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