Ukrainian-Speaking Migrants' Concerning the Use of Interpreters in Healthcare Service: A Pilot Study.

The aim of this pilot study was to investigate Ukrainian-speaking migrants' attitudes to the use of interpreters in healthcare service in order to test a developed questionnaire and recruitment strategy. A descriptive survey using a 51-item structured self-administered questionnaire of 12 Ukrainian-speaking migrants' and analyzed by the descriptive statistics. The findings were to have an interpreter as an objective communication and practical aid with personal qualities such as a good knowledge of languages and translation ability. In contrast, the clothes worn by the interpreter and the interpreter's religion were not viewed as important aspects. The findings support the method of a developed questionnaire and recruitment strategy, which in turn can be used in a larger planned investigation of the same topic in order to arrange a good interpretation situation in accordance with persons' desire irrespective of countries' different rules in healthcare policies regarding interpretation.

INTRODUCTION

Canada is a growing multilingual country representing 20.6% of immigrants, where 6.5% of all immigrants reported not being able to communicate in either English or French (Canada’s official languages), and this group is growing [1]. Thus, language is often considered crucial in all healthcare services [2]. Previous studies have documented that language barriers lead to miscommunication, which in turn leads to healthcare inequality [3], increasing risks to patient safety [4] and obstructing access to healthcare [5]. In order to address language barriers between patient and healthcare professionals, and thus increase equity and quality of healthcare, it is mostly accepted that some form of interpretation should be provided [2]. A previous study in Canada [6] showed that some healthcare professionals can have 20 requests per day for interpretation services, and the requirements cover some eight to ten languages. Thus, the finding calls for an appropriate interpreter’s service in Canada’s healthcare system. Therefore, this study aims to study Ukrainian-speaking immigrants’ attitudes to the use of interpreters in Canadian healthcare. The majority of all immigrants in Canada are from Europe, and persons of Ukrainian origin represent Canada’s ninth largest immigrant group [1], making it the world’s third largest Ukrainian population outside Ukraine itself and Russia.

No previous study gathering quantitative information about European migrants’ attitudes to the use of interpreters in Canadian healthcare encounters has been found. However, there is a previous quantitative study of Arabic-speaking migrants in Sweden [7] and Micronesian-speaking migrants in the United States (US) [8]. The findings were in opposite, Arabic-speaking migrants in Sweden found that they preferred using a professional interpreter [7] and Micronesian-speaking migrants in the United States found that they preferred using a family member or friend as interpreter [8]. There are also previous qualitative studies of Bosnian/Croatian/Serbian [9] and Arabic [10] speaking in Sweden, Bosnian/Croatian/Serbian-speaking and Russian-speaking migrants Ireland [11]. Informants in those studies [9-11] mostly preferred a professional interpreter who were highly skilled in medical terminology and language, with professional attitude. Those findings were contrary to previous qualitative studies, mainly of people of East Asian origin in the UK, where participants preferred to use family members as interpreters [12, 13] with expectations to empathize with them and understand and relate to their situations [13]. Internationally, there are differences concerning the legal right a person has to access across language barriers. In Sweden there is law [14] that all people who may communicate in another language in contact with healthcare services are permitted to access interpretations services. In contrast, in the UK the law is vague concerning what language rights individuals have [15] and in Canada there is no legislative framework requiring the provision of interpretation service to all people [16]. Due to these legal differences between countries in access to interpretation service, it is important to investigate Ukrainian-speaking migrants’ attitudes to the use of interpreters in Canadian healthcare to understand how migrants’ opportunities and worries regarding interpreters may vary both within and across cultural/linguistic populations and to understand the significances of different attitudes for planning responsive services group in order to deepen our understanding of the Ukrainian speaking person’s attitudes of using interpreters to obtain a more complete understanding of the problem area. Furthermore, this pilot study is intended to test the translated questionnaire and whether the participant recruitment strategy is workable, acceptable and manageable in order to use the findings to assess the feasibility of conducting a stronger, larger investigation on the same subject.

Aim

The aim of this pilot study was to investigate Ukrainian-speaking migrants’ attitudes to the use of interpreters in healthcare service in order to test a developed questionnaire and recruitment strategy.

MATERIALS AND METHODOLOGY

Design

A descriptive survey using a structured self-administered questionnaire [17] concerning Ukrainian-speaking migrants’ attitudes to the use of interpreters in healthcare was used to pilot-test the translated questionnaire, and whether the participant recruitment strategy is workable, acceptable and manageable. It is planned to use the lessons from the pilot study to assess the feasibility of developing a stronger, larger investigation on the same subject [17].

Setting

A Canadian province with the second largest percentage of Ukrainians, where 10% of the populations were Ukrainians, was studied. The participants lived in a metropolitan region with many immigrants, both newcomers and older immigrants; in addition, the city has the largest Ukrainian population in Canada [1].

Sample

A convenience sampling of Ukrainian-speaking adults (over 18 years) who use interpreters in healthcare with different gender, age, educational level and length of residence in Canada participated in the pilot study.

To come into contact with participants the author used snowball sampling by asking a voluntary representative at a Ukrainian adult education facility for immigrants to distribute questionnaires to participants who met the study’s inclusion criteria. A prepared envelope with written information and a questionnaire were given by the representative to the voluntary participants so they could answer when appropriate. The written information included data about the aim of the study, focusing on the use of an interpreter in healthcare encounters from their perspective, the implementation of the study and the ethical considerations. Thus, the questionnaire was to be returned in an envelope to the representative at the adult education facility for immigrants which in turn sent it to the author. The authors’ contact details were included in case the participants had any questions. Participants did not have to write their names if they did not want to.

Fifty questionnaires were distributed in March 2013 at an adult education facility for immigrants. In total 12 persons returned the questionnaire giving a response rate of 24%. All were in residence in Canada from 1994 to 2012 (median 1996) with a high education level.

Data Collection

Data were collected using a 51-item questionnaire with permission from the developer of the original version [7]. The original survey was grounded on four previous qualitative studies [9, 18-20] (for more details see [7]). The questionnaire was used to investigate attitudes, opinions, preferences and past experiences concerning the use of interpreters in healthcare and it included some additional background data questions. This type of survey is useful in obtaining data directly from participants and is effective in capturing values and attitudes [17].

The questionnaire was originally written in Swedish (for more details see [7]) and was translated and adapted into English by three researchers, experienced in the use of interpreters in a healthcare setting and in quantitative methods [17, 21-23]. After the preliminary individual translation and adaptation, the researchers compared documents and agreed on a final document. The translated questionnaires’ sent to a bilingual person (English and Ukrainian) who was selected for her fluency in English and Ukrainian (her mother tongue is Ukrainian), familiarity with both cultures and a professional background (she works as a language teacher) [21, 24]. The translation from English to Ukrainian was certified as accurate by a bilingual person fluent in both English and Ukrainian and familiarity with both cultures that led to no correction of language [21-23].

The survey was arranged in three areas with statements about the use of interpreters in healthcare: as a communication aid (21 items); the professional and personal qualities of an interpreter (19 items); modes of interpretation and the type of interpreter (11 items). The 51 items are rated on four-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree), i.e. the higher the values, the stronger the agreement [7]. The questionnaire took on average approximately 15 min to complete. Since the participants mostly answered with only two values, either disagreeing or agreeing, the answers with strong disagreement and agreement were summed with these to give dichotomous variables showing either a pessimistic or an optimistic view [7].

Data Analysis

Completed surveys were coded, cleaned and computerized. Descriptive statistics, in terms of frequencies and percentages [17] were used to analyze the three areas of the use of interpreters with the help of SPSS version 20 SPSS Inc, Chicago, IL, US.

Ethical Considerations

The common ethical principles [25] were followed. The participants received written information in Ukrainian about the study, confidentiality and the right to withdraw. The questionnaires were anonymous, coded by number, and the analysis and presentation of the data were done on a group level which conceals the participants’ identity in order to ensure confidentiality. All the collected data were stored in a locked space at the author’s workplace, accessible only to the author. According to the common ethical principles [25] approval by an official research ethics committee was not required because the research study posed no physical or mental risk to the participants and did not treat participants’ personal data.

RESULTS

The main study findings were that having an interpreter with a good knowledge of languages and translation ability as an objective communication aid and a practical aid an important aspect (see Tables -). However, personal qualities such as the clothes worn by the interpreter and the interpreter’s religion were not seen as the important aspects. Participants felt more trust in family members as interpreters than having an unknown person acting as interpreter.

DISCUSSION

This pilot study, to my knowledge, is first study to investigate Ukrainian-speaking individuals’ attitudes to the use of interpreters in Canadian healthcare service. The findings showed that it was important that an interpreter act as an objective communication and practical aid and having personal qualities such as a good knowledge of languages and translation ability. Other personal characteristics such as the clothes worn by the interpreter and the interpreter’s religion were not viewed as important aspects. Ukrainian-speaking migrants’ felt more trust in family members as interpreters than an unknown person acting as interpreter.

The finding of the pilot study was that Ukrainian-speaking individuals experienced trust in using a family member/friend as interpreter more than an unknown person as interpreter, and they could not see any risk in using family members as interpreters in a healthcare encounter. This finding is supported by previous qualitative studies, mainly of Eastern Asian migrants in the UK [12, 13] and a previous quantitative study concerning Micronesian-speaking migrants in the United States [8]. Thus, the pilot study finding is in contrast to previous qualitative studies from European migrants’ perspective in Sweden [9] and in Ireland [11], where participants described the family member’s inability to fully grasp the language and preferred to use a professional interpreter. Advantages of using family members as interpreters included greater privacy, support in the consultation and a shared understanding of advice and instructions [12]. In contrast, the advantages of using professional interpreters included significantly reducing errors of potential clinical significance [26] and better patient reports on quality treatment [27]. The dissimilarities between studies concerning the preferred type of interpreter could be explained by the countries’ different policy rules regarding interpretation in healthcare. In Sweden it is a legal right [14] to access interpreting and translation services in all contacts with authorities; in contrast, the legal right is unclear in the UK [15] and absent in Canada [16]. However, the finding emphasizes the importance of ensuring optimal communication in the interpretation situation when family members act as interpreters, regardless of the country’s legal rights and the person’s background, in order not to compromise patients’ clinical safety [7, 9, 10, 20].

A result in accordance with a previous quantitative study concerning Arabic-speaking persons in Sweden [7], was that confidence in the interpreter was not associated to the professional interpreter’s religion. Otherwise, the qualities of interpreters experienced by Ukrainian participants were mostly in agreement with previous qualitative studies of patients’ [9, 13], healthcare staff [18] and family members [20]. Feeling trust in interpreters was perceived as a benefits for cross-cultural communication [28] and for providing quality healthcare [29, 30]. This aspect is important to consider when arranging the interpretation, to adjust to the possibilities of the interpretation context and the patient’s background characteristics [7, 9, 10, 20]. A new finding compared to the quantitative study among Arabic-speaking migrants in Sweden [7] was that all participants described the willingness of healthcare professionals to book an interpreter when needed. It seems reasonable to assume that differences between studies could be due to the translation of the questionnaire used for the investigation in different areas, or participants did not read the statement correctly because it was negatively formulated to test opinion [7]. Furthermore, it can be explained by variations in terms of the expectations, requirements and availability of interpretation services that exist in Canadian and Swedish healthcare organizations [31].

A strength of this pilot study is that the participants were recruited with snowball sampling from a particular organization representing the province and metropolis with the largest Ukrainian population in Canada [17]; participants were of different ages, length of residence in Canada and with high education levels. There are several limitations to this study. A weakness of the recruitment procedure of contacting representatives of adult education could be seen as a threat to the dependency of the participants and may influence the outcome of the pilot study. The relationship between the volunteer and the participants, such as their different hierarchical, cultural and sociodemographic backgrounds, may have led some respondents to feel less trust, to practice and self-censorship, and to be afraid to express their views [23]. To minimize the risk of bias, the questionnaire was to be return to the volunteer representative, who then sent it author.

Developing a new structured self-administered questionnaire in another language requires as much work as developing an original questionnaire [17, 22]. The goal of the translation of data was to achieve semantic equivalence so as to preserve the underlying meaning of the original expression rather than the exact wording [21-23]. The first step was that the translation of data started with the selection of a translators’ team who worked independently to complete a draft translation of the source questionnaire, including the instructions. Second, for translation from Swedish to English, the team included native Swedish speakers with expertise in developing questionnaires, good English ability, familiarity with both cultures and the theoretical keystones of the concept. Third, for translation from English to Ukrainian, was chosen independent native Ukrainian speaker with expertise in translation and familiarity with both cultures. Finally, the questionnaire was pilot-tested by Ukrainian-speaking persons for accuracy in the transcriptions with no language corrections; nevertheless, the newly structured self-administered questionnaire should be tested in a full psychometric evaluation with a large sample of respondents [17, 21-23]. The small number of participants and limited sample sizes restricted the ability of the study to generalize from the findings [17]. Though these limitations, the investigation results support the findings from previous quantitative [7] and qualitative [9, 10] studies of a different cultural and language migrant group and provide a deeper understanding of the Ukrainian speaking person’s attitudes of using interpreters.

Conclusion

This pilot study supported a previous quantitative study from another migrant group with a different cultural and language background in a country with legal right in access to interpretation service. Similarities found were the view of an interpreter as an objective communication aid with a good knowledge of languages and good translation ability. Experiences differed as to whether the interpreter should share the same religion as the patient and willingness of healthcare professionals to book an interpreter. The findings support the method in terms of the questionnaire and recruitment strategy is workable, acceptable and manageable for participants, so that it can be used in a larger psychometric evaluation of the same topic with a large sample of participants. The implications of the pilot study, the nurses need to be of aware of differences between countries concerning the legal right a person has to access across language barriers affected some of the expectations and requirements of the use of interpreters among immigrants to enhance the receptivity and utilization of trained language interpreters.

CONFLICT OF INTEREST

The author confirms that this article content has no conflict of interest.

Table 1

Attitudes concerning the communication aid from the Ukrainian-speaking migrants perspective.

Variable	N	Agree N (%)	Disagree N (%)
helps me only with translation	12	12 (100%)	0 (0%)
to find the way within health care	12	12 (100%)	0 (0%)
to express myself clearly	12	12 (100%)	0 (0%)
always book an interpreter in advance	11	11 (100%)	0 (0%)
if I do not feel confidence for a certain interpreter, I wish to have the possibility to replace him/her	12	11 (92%)	1 (8%)
no importance to have the same interpreter at healthcare encounters	12	11(92%)	1 (8%)
Importance to have a secluded a room with the door closed to be able to understand all information and feel safe	12	10 (84%)	2 (16%)
to being able to express myself	12	10 (83%)	2 (17%)
only translate	12	10 (83%)	2 (17%)
difficult to guarantee that the interpreter will not spread it to others	12	9 (75%)	3 (25%)
no importance of too haves an interpreter at every consultation	12	8 (67%)	4 (33%)
to talk through an interpreter feels like being disabled (or handicapped)	12	8(67%)	4 (33%)
helps me with transport both before and after consultations	11	7(64%)	4 (36%)
the interpreter shall not interpret literally	12	6(50%)	6 (50%)
presences of an interpreter imply that I forget to tell some things	12	6(50%)	6 (50%)
to talk about sensitive matters through an interpreter makes me feel insecure.	12	5 (42%)	7 (58%)
get a feeling of uncertainty	12	5(42%)	7 (58%)
when booked interpreters have not turned up	7	3 (43%)	4 (57%)
as a reduced intimacy between healthcare staff and me	12	4 (33%)	8 (67%)
no importance in which room an interpretation is made.	12	3 (25%)	9 (75%)

Table 2

Attitudes concerning the professional and personal qualities of an interpreter from the Ukrainian-speaking migrants’ perspective.

Variable	N	Agree N (%)	Disagree N (%)
has a great ability to translate	12	12 (100%)	0 (%)
importance to have confidence for an interpreter for whether I will honestly tell health care staff about my illness	12	12 (100%)	0 (0%)
show me respect	12	11 (92%)	1 (8%)
no importance of interpreters religion	12	10 (84%)	2 (16%)
knowledge both in the language and the terminology used in healthcare	12	10 (84%)	2 (26%)
I know from which country the interpreter comes from	12	8 (67%)	4 (33%)
no importance to introduce him/herself to me	12	7 (58%)	5 (42%)
no importance what cloths an interpreter use and whether he/she is challenging dressed	12	7 (58%)	5 (42%)
the same gender as myself	12	6 (50%)	6 (50%)
The interpreter's age is of no importance for the translation	12	6 (50%)	6 (50%)
no importance which religion the interpreter belongs to	12	6 (50%)	6 (50%)
no importance that an interpreter is trained	12	5 (42%)	7 (58%)
no importance of that interpreter talk the same dialect as me	12	4 (33%)	8 (64%)
no importannce that the interpreter is neutral and impartial	12	4 (33%)	8 (67%)
no importance of the interpreter's training in the language and medical terminology, which is used in healthcare.	12	3(25%)	9 (75%)
it is not important that interpreter keep code of confidentiality	12	1 (8%)	11 (92%)
more confidence for an interpreter who has a similar outfit as my own	12	1 (8%)	11 (92%)
no importance whether an interpreter can speak both languages	12	0 (%)	12 (100%)
confidence in younger interpreters than in older	12	0 (0%)	12 (100%)

Table 3

Attitudes concerning the modes of interpretation and the type of interpreters from the Ukrainian-speaking migrants’ perspective.

Variable	N	Agree N (%)	Disagree N (%)
bilingual healthcare staff is good to use as interpreters	12	11 (92%)	1 (8%)
no risk that all information will not be translated when bilingual healthcare staff act as interpreters	12	11 (92%)	1 (2%)
good to use an trained interpreter,	12	10 (84%)	2 (16%)
feel confidence in using a family member/ friend as interpreter than on an unknown person being an interpreter	12	9 (75%)	3 (25%)
feel confidence in using a family member/ friend as interpreter for I get support	12	9 (75%)	3 (25%)
not risk that the family member/ friend as interpreter do not translate everything	12	9 (75%)	3 (25%)
prefer to use a family member/friend as interpreter	12	8 (67%)	4(33%)
prefer to use an interpreter on place	12	7 (58%)	5 (42%)
no difference between telephone interpreters or interpreter on place	12	5 (42%)	7 (58%)
prefer to use telephone interpreter during sensitive investigations	12	5 (42%)	7 (58%)
no importance to being able to see the body language of the interpreter	12	5 (42%)	7 (58%)