An exploratory study of language interpretation services provided by ...

Preliminary communication

......................................................................................................................................................

"

An exploratory study of language interpretation services provided by videoconferencing D Jones*, P Gill {, R Harrison*, R Meakin* and P Wallace* *Department of Primary Care and Population Sciences, RFH & UCL School of Medicine, London; { Health Inequalities Research Group, Department of Primary Care and General Practice, University of Birmingham, UK

Summary We explored the feasibility and acceptability of the remote provision of a language interpretation service during general practice consultations. Three methods were used to provide an interpretation service: a physically present interpreter (PI), a remote interpreter accessed using an ISDN videoconferencing link at 128 kbit/s (VI) and a remote interpreter accessed by telephone (TI). Thirty-six non-English-speaking patients were invited to take part and 35 agreed to do so. Twenty-nine (83%) of the patients recruited were female. The age range of the participants was 24–51 years. Fourteen consultations took place with a physically present interpreter, 11 using videoconferencing and 10 using the telephone. Mean scores on the Patient Enablement Instrument were 5.2 for the PI group, 2.3 for the VI group and 5.1 for the TI group. Mean scores on the Medical Interview Satisfaction Scale were 5.3 for the PI group, 4.9 for the VI group and 5.3 for the TI group. The visual quality and sound quality of remote interpreting were satisfactory. Both videoconferencing and hands-free telephones can deliver an acceptable interpreting service in primary care.

Introduction

............................................................................... There is a growing need to provide readily accessible interpreting services for the non-English-speaking population who use the UK National Health Service (NHS)1,2. The large number of languages spoken and the dispersed nature of general practice surgeries and other primary care sites make it difficult to deliver adequate language services, especially in London, where 20 different language groups of substantial size have been identified3. Informal interpreters, such as auxiliary health-care workers, are often used but this can result in important interpreting errors4. Alternatively, relatives (especially children) may be used, although this is not acceptable to many patients and doctors1 . Because of these problems, services which provide telephone access to interpreters have been developed. However, these have been criticized on the grounds that the non-verbal aspects of communication are not Accepted 7 October 2002 Correspondence: David Jones, Department of Primary Care and Population Sciences, RFH & UCL School of Medicine, Whittington Hospital, London N19 5NF, UK (Fax: +44 207 281 8004; Email: [email protected])

Journal of Telemedicine and Telecare 2003; 9: 51–56

available to the interpreter5, who might therefore miss an inference or not be able to gauge easily whether information has been clearly understood6. Moreover, it has been claimed that, because of the lack of visual input, including facial expression and gestures, doctors and patients may feel insecure about the quality of telephone interpretation7 and that the fluency of interaction may be reduced8. We have carried out a pilot study of the use of videoconferencing to provide a remote interpretation service for non-English-speaking patients in primary care.

Methods

............................................................................... The study was carried out in a general practice run by a single physician in an area of north London with a large Turkish-speaking population (who represent 10% of the local population). In this area requests for Turkish language interpretation services exceed those for other languages. Before the study, the practice used physically present interpreters and also had access to a telephone interpreter.

D Jones et al.

Videoconferencing for remote interpreting

Ethics committee approval was obtained and all patients recruited gave written consent using a consent form translated into Turkish.

Interventions Three interpreting methods were used: a physically present interpreter (PI), a remote interpreter accessed using an ISDN videoconferencing link at 128 kbit/s (VI) and a remote interpreter accessed by telephone (TI). The same interpreter and general practitioner were used for all consultations. The interpreter was female, had worked in the NHS as a medical interpreter and had extensive experience of providing telephone interpreting to general practitioners. The seating arrangements varied for each interpreting technique: (1) In the PI condition, a triangular seating arrangement was used, with the doctor facing both interpreter and patient. (2) In the VI condition, the video-camera faced the patient and the seating was arranged to allow both the doctor and patient to have a comfortable view of the screen displaying the image of the interpreter. In the top right-hand corner of the screen there was a small image showing what the interpreter could see. (3) In the TI condition, a hands-free conference phone was placed between the doctor and patient. For the remote services, the interpreter was located in a room in the health centre connected to the consulting room by a telephone line or a digital line for videoconferencing. A brief explanation to patients of the process was provided as part of obtaining consent, including reassurance that, in the VI condition, the cameras would be switched off during physical examinations involving the removal of clothing.

Recruitment The practice had previously identified all patients with a language barrier by an entry in the computer records made by the doctor or nurse practitioner at first contact with the patient. All appointments were initiated by the patient. All patients who attended the clinic were invited to participate in the study provided they had been seen in the practice at least once previously. Only one interpreting method was used each week and the interpreting method was changed weekly in strict rotation. In this way the subjects were allocated to a particular type of intervention depending on which week they had their appointment. To minimize administrative confusion, a part-time Turkish-speaking

52

receptionist was employed to book appointments. Patients were invited to participate in the study by a Turkish-speaking researcher. At the consultation, the patient’s gender and age, principal reason for consulting and the duration of the consultation were recorded by the general practitioner.

Questionnaires After the consultation, each patient completed the following questionnaires, which were administered by the Turkish-speaking researcher: (1) The Patient Enablement Instrument (PEI)9. This measures the degree to which patients have been enabled by the consultation to understand and cope with their condition. The scores range from 0 to 12, with high scores indicating high levels of enablement. (2) A 21-question version of the Medical Interview Satisfaction Scale (MISS-21) questionnaire10,11 . This measures patient satisfaction with individual consultations in UK general practice. It assesses satisfaction with ease of communication (on the Communication Comfort subscale), the emotional content of the consultation (on the Rapport subscale), relief of concerns (on the Distress Relief subscale) and prescribed treatment (on the Compliance Intent subscale), as well as an overall measure of satisfaction. The scores range from 1 to 7 on each subscale, as well as for the overall measure, with 7 indicating the highest level of satisfaction. (3) Four questions designed to explore the patient’s perceptions of the quality of communication and degree of discomfort with the interpreting process and sense of wellbeing after the consultation. In addition, patients allocated to the TI condition were asked about sound quality, patients allocated to the VI condition were asked about sound and picture quality, and both TI and VI patients were also asked if they would be prepared to use these techniques again. None of the VI patients had previous experience of this technique and they were invited to compare videoconferencing with other types of interpreting service by responding to a further question. All three instruments were translated into Turkish and back-translated independently into English by a second interpreter using current guidelines12. The Turkish translation obtained was explored by a focus group of Turkish-speaking bilingual health-care workers and monolingual non-English-speaking Turkish participants for face and content validity. The focus group Journal of Telemedicine and Telecare

Volume 9

Number 1

2003

D Jones et al.

was tape-recorded. The translation was modified further by this group and returned to the independent translator. The resulting translation was again explored by the focus group and a final version agreed13.

Semistructured interviews Four subjects from each group were randomly selected for interview to obtain a range of views on the interpreting services. Participants were also encouraged to discuss their past experiences of interpreting. The interviews were conducted with help from another interpreter, in the participants’ homes, and lasted up to 30 min. The interviews were recorded and all the English-language sections transcribed before analysis. To maximize reliability and validity, all reports were read and themed independently by two of the researchers using the technique of charting, which involved reading and re-reading the transcripts and independently selecting and reorganizing responses according to themes. The two researchers then met and agreed on the themes and any disagreement was resolved by discussion14.

Results

............................................................................... Thirty-six patients were invited to take part and 35 agreed to do so. Twenty-nine (83%) of the patients recruited were female. The age range of the participants was 24–51 years. A total of 35 interpreter-mediated consultations took place over two months. There were 14 patients in the PI group, 11 in the VI group and 10 in the TI group. The consultations lasted a mean of 13 min (range 6–23 min) for the PI group, 15 min (range 10–23 min) for the VI group and 12.5 min (range 6–28 min) for the TI group. The reasons for consulting are shown in Table 1. All the patients completed the questionnaires and none of the items were unanswered.

Questionnaire responses The responses to the MISS-21 and PEI are shown in Table 2. Mean MISS-21 scores for all three interpreting methods exceeded the midpoint on each subscale (3.5). Mean PEI scores for all interpreting methods fell below the midpoint of the scale (6). The mean PEI score of the VI group (2.3) was lower than that of the PI (5.2) and TI (5.1) groups. Responses to the supplementary questionnaire are shown in Table 3. All patients in all three groups felt that they had been understood by the interpreter. A smaller proportion in the VI group agreed that they Journal of Telemedicine and Telecare

Volume 9

Number 1

2003

Videoconferencing for remote interpreting

Table 1 Reasons for consultations Presenting complaint

Duration of consultation (min)

VI group (nˆ11) Contraceptive advice Letter re asylum claim Loin pain Otitis externa Asthma Knee pain Period pain Migraine Pleurisy Chest pain Vaginal discharge

14 12 23 12 19 17 14 13 17 15 10

PI group (nˆ14) Repeat certificate/medication Back pain Depression Eye pain Vaginal infection Dislocated shoulder Contact dermatitis Depression Vaginal discharge Depression Dysuria Headache Migraine Depression

10 11 9 14 19 16 10 23 10 12 10 11 15 6

TI group (nˆ10) Eye pain Pelvic pain Bereavement Antenatal Housing Certificate/report Hyperemesis Hormone replacement therapy Sore throat Dermatitis

6 16 11 14 28 9 14 10 8 9

PI, interpreter physically present; VI, remote interpreter accessed using an ISDN videoconferencing link at 128 kbit/s; TI, remote interpreter accessed by telephone.

had been understood by the doctor (73% compared with 100% of patients in the other two groups). The picture quality of the videoconferencing appeared to be acceptable to all patients but two patients were unable to agree that the sound quality of the videoconferencing was good. All patients in the VI and TI groups stated that they would be happy to use these remote interpreting methods again. More patients in the PI group admitted to feeling shy and nervous than in the groups using the remote interpreting methods.

Semistructured interviews The following themes emerged: (1) ready availability of interpreting is crucial;

53

D Jones et al.

Videoconferencing for remote interpreting Table 2 Patient satisfaction and patient enablement, by intervention Mean scale score (95% CI) Instrument

TI group (nˆ10)

VI group (nˆ11)

PI group (nˆ14)

Medical Interview Satisfaction Scale Communication Comfort subscale Compliance Intent subscale Distress Relief subscale Rapport subscale Overall satisfaction

5.0 5.2 5.2 5.6 5.3

4.4 4.4 4.6 5.5 4.9

4.6 5.0 5.3 5.9 5.3

Patient Enablement Instrument

5.1 (2.9–7.3)

(4.2–5.8) (4.6–5.8) (4.7–5.6) (5.3–6.0) (5.0–5.6)

(4.0–4.7) (4.1–4.7) (4.1–5.2) (5.0–5.9) (4.6–5.2)

2.3 (0.8–3.7)

(4.2–5.1) (4.5–5.4) (4.9–5.8) (5.5–6.3) (5.0–5.7)

5.2 (3.2–7.2)

Table 3 Patient perceptions of the interpreter services No. (%) of participants who agreed, strongly agreed or very strongly agreed with the statement Statement

PI group

VI group

TI group

I felt the interpreter understood what I was saying I felt the doctor understood my problem(s) I felt shy and nervous As a result of my consultation I feel much better The sound was good The picture was good I would be happy to use this service again Compared with other types of service I felt video-interpreting was better

14 (100%) 14 (100%) 5 (36%) 14 (100%) N/A N/A N/A N/A

11 (100%) 8 (73%) 1 (9%) 8 (73%) 9 (81%) 11 (100%) 11 (100%) 10 (91%)

10 (100%) 10 (100%) 1 (10%) 10 (100%) 10 (100%) N/A 10 (100%) N/A

N/A, not applicable. These supplementary questions explored the remote techniques and were not applicable to the PI group and the question about picture quality and video-interpreting was not applicable to the TI group.

(2) use of relatives as interpreters is often, but not always, unacceptable; (3) patients are reluctant to express a preference for a particular interpreting method; (4) some patients preferred the videoconferencing to the telephone; (5) videoconferencing can create a ‘camera shy’ response.

patients expressed concern about being seen by the interpreter when being examined by the doctor, and there appeared to be an element of ‘camera shyness’ associated with videoconferencing.

The strongest theme to emerge from the interviews was the appreciation by patients of the need for readily available professional interpreters and the unacceptability of the provision of a medical service without an adequate interpretation service. Relatives acting as informal interpreters were acceptable to some patients, but not if the consultation was perceived as likely to lead to intimate disclosures. None of the patients interviewed admitted to finding any of the three interpreting methods unacceptable and patients were reluctant to offer a preference for any one of the three. The response to video-interpreting was mixed. One patient expressed an appreciation of the additional communication dimension provided by the social presence resulting from a visual link. However, several

All three methods proved acceptable to the general practitioner and to the interpreter. The interpreter reported that the video-link had helped her to be more aware of the mental health of one patient whose body language and demeanour communicated her distress more effectively than her words. Aspects of meaning as well as elements of hard information may be lost in interpreted consultations15 and an increased appreciation by the interpreter of the emotional context may have an effect on the overall quality of the communication that is possible, especially in consultations involving distressed patients. The general practitioner and interpreter noted the difficulty of demonstrating the use of an asthma inhaler using a telephone link alone.

54

Journal of Telemedicine and Telecare

Views of the general practitioner and interpreter

Volume 9

Number 1

2003

D Jones et al.

Discussion

............................................................................... This pilot study suggests that videoconferencing and telephone interpreting are feasible for general practice consultations and that both appear to be acceptable to patients. The responses to the supplementary questions suggest that the great majority of patients were satisfied with the sound quality of the telephone service and the sound and visual quality of the videoconferencing service. Willingness to use these remote interpreting techniques was high in both groups and appears to confirm their suitability for general practice. The reluctance of patients when interviewed to offer an opinion on the superiority of one interpreting method over another may have been due to a lack of experience with different interpreting techniques, or a failure to see that the mode of interpreting may make a difference to the medical process5. The videoconferencing system used in this study was configured in such a way as to allow patients to see a view of themselves in the top right-hand corner of the monitor displaying the image of the interpreter. We suspect that this may partly explain the camera shyness noted in the qualitative material. The interpreter was familiar with physically present and telephone interpreting but did not receive formal training in interpreting using videoconferencing. The facial expression and angle of gaze of the interpreter may be particularly important, as we observed that the patient looked closely at the interpreter when speaking, rather than at the doctor. The use of translated questionnaires to explore satisfaction and enablement in interpreted consultations, when combined with semistructured interviews, is acceptable to patients and completion rates were high. Ideally, the translated versions should have been validated against an appropriate gold standard, but this was beyond the scope of the pilot study. The data suggest similar levels of patient satisfaction between groups, although the mean score on the PEI in the VI group was lower than in the other two groups. Although the numbers involved in this study do not allow quantitative comparison between the groups16, the lower patient enablement scores for videoconferencing may represent a real difference. If this is the case, one explanation may be that many of the patients in this study had not been exposed to video-interpreting before and that the lower enablement scores reflected the distraction caused by communication using an unfamiliar technique. The need to provide patients with a structured introduction to the equipment has been highlighted by a recent study17 and should form part of the methodology of future studies of videointerpreting services. Future research needs to test Journal of Telemedicine and Telecare

Volume 9

Number 1

2003

Videoconferencing for remote interpreting

whether enablement scores will be higher in patients already familiar with videoconferencing for interpreting in their consultations. The interview data suggest that the central issue for the patient is to have an interpreter of some kind and that generally patients prefer not to use family or friends. This finding is not new but it does reinforce the need to ensure that interpretation services can be supplied in a timely and accessible fashion in primary care. Patients appeared reluctant to express a preference for one interpreting method over another, but it appeared that both the general practitioner and the interpreter perceived advantages in using videoconferencing. It has been suggested that the added value of a videolink over a telephone is primarily the creation of a ‘social presence’, which permits participants to share a virtual space, to get to know the other conferencing partner better, and to feel comfortable while discussing complex issues18. The patient who commented that in videoconferencing it was ‘as though there was somebody there with you’ would seem to be valuing this ‘social presence’. Paradoxically, more patients in the PI group admitted to feeling shy and nervous, which suggests that for some patients the ‘social presence’ created by an interpreter being physically present in the room with the patient and doctor may be uncomfortable. Although the present study had a small sample size, the results suggest that, in terms of acceptability and patient satisfaction, videoconferencing and telephone interpreting may not differ greatly from the service offered by an interpreter who is physically present. If this were to be confirmed in a larger study, it would have implications for the delivery of primary care to non-English-speaking patients.

Acknowledgements: The study was funded by the North Central Thames Primary Care Research Network (NoCTeN). We thank all participants for taking part in this study and Semra Ahmet, Konce Sah and Arzu Kaya for providing the interpreting service.

References 1 Jones D, Gill P. Breaking down language barriers: the NHS needs to provide accessible interpreting services for all. British Medical Journal 1998;316:1476 2 Carr-Hill R, et al., eds. Lost Opportunities: The Language Skills of Linguistic Minorities in England and Wales. London: Basic Skills Agency, 1996 3 Baker P, Eversley J, eds. Multilingual Capital: The Languages of London’s Schoolchildren and Their Relevance to Economic, Social and Educational Policies. London: Battlebridge, 2000 4 Pochhacker F, Kadric M. The hospital cleaner as healthcare interpreter. A case study. The Translator 1999;5 (suppl. 1):161–78

55

D Jones et al.

Videoconferencing for remote interpreting

5 Levenson R, Gillam S, eds. Linkworkers in Primary Care. London: King’s Fund Publishing, 1998 6 Sanders M, ed. As Good As Your Word: A Guide to Community Interpreting and Translation in Public Services. London: Maternity Alliance, 2000 7 Riddick S. Improving access for limited English-speaking consumers: a review of strategies in health care settings. Journal of Health Care for the Poor and Underserved 1998;9 (suppl.):S40–S63 8 Wadensjo C. Telephone interpreting and the synchronisation of talk in social interaction. The Translator 1999;5 (suppl. 1):247–64 9 Howie JG, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. British Medical Journal 1999;319:738–43 10 Wolf MH, Putnam SM, James SA, Stiles WB. The Medical Interview Satisfaction Scale: development of a scale to measure patient perceptions of physician behavior. Journal of Behavioral Medicine 1978;1:391–401 11 Meakin RP, Weinman J. The Medical Interview Satisfaction Scale (MISS-21) adapted for British general practice. Family Practice 2002; 19:257–63

12 Gill PS, Jones D. Cross-cultural adaptation of outcome measures. European Journal of General Practice 2000;6:120–1 13 Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluating patientbased outcome measures for use in clinical trials. Health Technology Assessment 1998;2:1–74 14 Bryman A, Burgess RG, eds. Analysing Qualitative Data. London: Routledge, 1994 15 Cambridge J. Information loss in bilingual medical interviews through an untrained interpreter. The Translator 1999;5 (suppl. 1):201–19 16 Howie JG, Heaney DJ, Maxwell M, Walker JJ, Freeman GK. Developing a ‘consultation quality index’ (CQI) for use in general practice. Family Practice 2000;17:455–61 17 Tachakra S, Newson R, Wootton R, Stinson A. Avoiding artificiality in teleconsultations. Journal of Telemedicine and Telecare 2001;7 (suppl. 1):39–42 18 Cukor P, Baer L, Willis S, et al. Use of videophones and low-cost standard telephone lines to provide a social presence in telepsychiatry. Telemedicine Journal 1998;4:313–21

56

Journal of Telemedicine and Telecare

Volume 9

Number 1

2003