The His and Hers of Interpreting
A qualitative study on Gender Differences in Interpreter Mediated
Communication In General Practice
Salbi Garabetian
5878349
Master Thesis Persuasive Communication
Communication Science
Mw. Dr. B. C. Schouten
27-06-2014
2
ABSTRACT
Previous research show contradicting results on the use of informal interpreters and their effect on the quality of the communication process. Gender could possibly explain some earlier contradictory findings, due to possible differences between men and women in their expected gender roles and their motives for performing pro-social behavior. The aim of this qualitative study is to gain more insight into gender differences in Turkish informal interpreters’ perceptions of their task in interpreter mediated communication in general practice.
Seven female and four male Turkish informal interpreters participated in an interview. Data was analyzed using the Constant Comparative method.
Findings reveal differences in how female and male informal interpreters perceive their task during medical consultation in general practice. In general, Turkish male informal interpreters were more agentic (i.e. dominant, assertive) when performing their task in interpreter mediated communication, and performed more out of egoistic motives (i.e. self-focused). Female Turkish informal interpreters, on the other hand, performed their task for altruistic motives (i.e. other-focused) and were more communal in their communication, meaning they were more emotionally expressive and concerned with patients´ feelings than male informal interpreters.
The findings of this study show gender differences concerning informal interpreters’ role perspective and style of communication during consultations in general practice, which seem to be influenced by gender role beliefs (Bakan, 1966; Hofstede, 1983) and interpreters´ motives for performing pro-social behavior based on their gender (Brunel and Nelson, 2000).
Future research on this topic can be enhanced from a theoretical perspective by testing the above stated hypotheses of this study. It is also recommended to use a gender sensitive approach in interpreter mediated medical communication in general practice where GPs keep an open mind in their consultations regarding gender differences among informal interpreters and reflect on the way gender differences may play a role in interpreter mediated communication.
3
INDEX
1.Introduction 4
2.Theoretical Background 6
2.1 Professional and informal interpreters 7
2.2 Informal interpreters and gender differences 7
2.3 Interpreters´ roles 8
2.4 Informal interpreters and the quality of medical communication 10
3.Method 12 3.1 Participants 12 3.2 Procedure 12 3.3 Topic list 13 3.4 Data analysis 13 4. Results 14 4.1 Sample 14 4.2 Interpreters´ roles 15
4.3 Informal interpreters and the quality of medical communication 19
5. Conclusion and Discussion 23
References 28
4
1. INTRODUCTION
In 2013 around 21 percent of the total Dutch population consisted of migrants (CBS, 2013). As a consequence, many medical encounters take place between healthcare providers and patients belonging to different ethnic and cultural backgrounds. Several studies have shown that doctors are less successful in communicating with migrant patients than with patients belonging to the dominant culture; there is more miscommunication, as there is a lower understanding of each other´s health and cultural beliefs (Schouten, Meeuwesen, Tromp & Harmsen, 2007). In addition, general practitioners are less friendly and show less empathy during consultations with migrant patients. They often ignore the concerns of the patient and do not involve him or her in the medical decision process, mainly because the patient is perceived as being less assertive and expressive (Meeuwesen & Harmsen, 2007, Schouten, Meeuwesen, Tromp & Harmsen, 2007). These findings are alarming, because the quality of the communication process in healthcare has an important effect on treatment and health outcomes (Ferguson & Candib, 2002), such as compliance rates and patient satisfaction (Allen & Brock, 2002).
One of the most important barriers to effective communication with migrant patients is their lack of language proficiency in the dominant language (De Maesschalck, Deveugele & Willems, 2011). For instance, among Turkish migrants, the biggest minority group in the Netherlands, nearly 32 percent of the first generation has difficulties with conversations, whereas 21 percent faces difficulties with reading, hearing and talking in Dutch (CBS, 2013). A solution to tackle the language barrier in healthcare is to make use of professional interpreters. However, while the Federal Civil Service recommended in 2011 to achieve more equivalent health and healthcare for migrants and ethnic minorities by expanding the use of intercultural translators and integration of cultural competencies in all medical curricula, due to budget cuts the free provision of professional translation and interpreting services has ceased to exist from 2012 (Paauw, 2011). Therefore, the use of informal interpreters, such as family members and friends, which is already common in general practice, is likely to increase even more in the near future. Indeed, it has been estimated that over half of migrant patients with insufficient language proficiency in Dutch are accompanied by informal interpreters during medical encounters in general practice (Harmsen, 2003).
Previous research has documented that the use of informal interpreters has several negative effects on the quality of the communication process, such as translation inaccuracies or omission of relevant information (Aranguri, Davidson & Ramirez, 2006;
5
Flores, Laws, Mayo, Zuckerman, et al., 2003; Twilt, 2007). Conversely, some positive effects have also been reported, such as a higher degree of trust among patients towards the informal interpreter and empowerment of the migrant patient (Cohen, Moran-Ellis, & Smaje, 1999; Green, Free, & Bhavnani, 2005). Because results are contradictory and inconclusive, more knowledge is needed about informal interpreter-mediated consultations (Brisset, Leanza & Laforest, 2012).
Therefore, the overall aim of the present study is to gain more insight into informal interpreters’ perspectives of interpreted communication in general practice by generating new hypotheses. Specifically, this study will investigate gender differences in informal interpreters’ perceptions, because taking gender into account could possibly explain some earlier contradictory findings from previous research, due to possible differences between men and women in, for instance, motives for performing pro-social behavior (Basil, Ridgeway & Basil, 2008; Brunel & Nelson, 2000; Underwood & Moore, 1982) and expected gender roles (i.e. masculinity versus femininity; Hofstede, 1980). To the best of our knowledge, this will be the first study to investigate interpreter-mediated communication taking a gender-based approach, thereby providing new information that might shed some light on previous differences in results on informal interpreting in general practice.
This study will focus on informal interpreters of Turkish decent, because they form the largest non-western minority group in the Netherlands (CBS, 2013). In addition, Turkish migrants visit the GP more often than native Dutch patients, and are often accompanied by informal interpreters making them the most appropriate primary target for this qualitative analysis (Meeuwesen & Twilt, 2011). The proposed study will explore gender differences in perspectives of Turkish-Dutch informal interpreters regarding interpreter-mediated communication in general practice by proposing the following research question:
“Are there differences between men and women in how Turkish-Dutch informal interpreters perceive their task during medical consultations in general practice?”
The results of this study can incite future research to include gender differences into this field in order to enhance the knowledge on this topic from a theoretical point of view by testing the generated hypotheses of this study. The results of this study can also be used to encourage a more gender sensitive approach, where the interpreters´ gender characteristic and its influence on the communication in interpreter mediated communication is taken into
6
consideration by the GP. GPs can do that by keeping an open mind in their consultations regarding gender differences among informal interpreters and reflect on the way gender differences may play a role in interpreter mediated communication.
2 THEORETICAL BACKGROUND
This chapter will discuss theories regarding interpreter mediated communication in healthcare. To achieve a better understanding of the role of informal interpreters, first a distinction between professional and informal interpreters is provided. Then, gender differences within interpreter mediated communication will be discussed, followed by interpreters´ roles and the influence of the interpreter on the quality of the communication. From this theoretical basis several sub-questions will arise, which will assist in answering the general research question.
2.1 Professional and Informal Interpreters.
Healthcare providers and official bodies often recommend the use of professional interpreters during a medical consultation (Hsieh, 2006; Swerissen, Belfrage & Weeks, Jordan, Walker, Furler et al., 2006). Professional interpreters are people who have enjoyed an education to act as an interpreter. However, the use of professional interpreters is not mandatory and also, no longer funded in the Netherlands. Therefore, Dutch healthcare providers and migrant patients with insufficient language proficiency in the dominant language often rely on informal interpreters instead (Meeuwesen & Twilt, 2011). Informal interpreters do not have formal educational qualification and could be friends, acquaintances or family members of the patient (Flores, Laws, Mayo, Zuckerman, Abreu & Medina et al., 2003; Rosenberg, Leanza, & Seller, 2007; Rosenberg, Seller, & Leanza, 2008; Twilt, 2007). Informal interpreters could also be unknown to the patient. In that case the informal interpreter is called an ad hoc interpreter, which could be a professional such as a physician assistant who happens to speak the language or a lay counselor such as a fellow patient in the waiting room who speaks the language of the patient (Angelelli, 2004; Aranguri et al., 2006; Green et al., 2005; Rosenberg et al., 2007, Rosenberg et al., 2008).
The difference between professional and informal interpreters can further be explained by Habermans´ theory of communicative action (1987), which distinguishes between the System and the Life world. The system (i.e. economy, state) is defined as the strategic actions that strive for efficiency and power, whereas the life world is defined as the communicative actions within the social sphere (Hasselkus, 1992, Mishler, 1984; Twilt,
7
2007). In the world of GPs, the ´voice of the medicine´ is represented. This voice represents objective, technical and scientific facts; the context of the medical world. On the other hand, the world of the patient is represented by the ´voice of the life world´, consisting of subjective concepts such as the experiences and perceptions of the patient (Mishler, 1984). The informal interpreter is often described as a life world agent functioning as a bridge between the patient and the GP, because informal interpreters are considered to be more capable of understanding the world and the feelings of the patient and better in transferring it to the GP in comparison to professional interpreters (Twilt, 2007).
The informal interpreter thus often brings together the voice of the life world and the voice of medicine in medical encounters. Professional interpreters often neglect subjective statements of the patient and are trained to translate the exact words of the patient to the GP and vice versa. The focus is therefore on objective facts and not on subjective experiences (Twilt, 2007).
2.2. Informal interpreters and gender differences
This chapter will focus on the dimension of masculinity versus femininity to explain possible gender differences between female and male informal interpreters regarding their perspectives of their interpreting task in general practice.
Hofstede (1983) designed a framework to distinguish cultural differences by the use of four dimensions, among which masculinity versus femininity. In masculine cultures, the difference between men and women is very present and a clear and strict division of gender roles is made. Gender roles are the shared beliefs that apply to persons on the basis of their socially identified sex (Eagly, 2009), and are both descriptive and prescriptive, meaning that they specify what men and women usually do, and what is expected from them to do. In confusing situations, people tend to act according to the descriptive aspect of their gender roles, in other words the stereotypes, which tells them what is typically for their sex. The prescriptive aspect of a gender role informs people of what is considered as appropriate and desirable for their sex in their cultural context. People tend to live up to this prescriptive aspect in order to gain social approval or to boost their self-esteem (Wood & Eagly, 2009).
In feminine cultures, like the Dutch culture, gender differences are often overlapping. Men and women often have the same caretaking role. In addition, problems are solved within a group and one will rely on outsiders for help when needed. In feminine cultures, men and women work together and are there for each other in order to achieve the ultimate goal, which is a higher quality of life (Hofstede, 1983). Contrary to the Dutch culture, the
8
Turkish culture is a rather masculine culture. In this culture it is expected of men to be assertive and hard, while women are expected to be caring, modest and tender. In addition, men are expected to focus on achieving material success while women are expected to focus on the quality of life and existence in general (Hofstede, 1983).
Bakan (1966) identified two dimensions underlying gender beliefs. The first dimension is the communion dimension, which refers to the connection with others and the second dimension agency, refers to self-assertion. Women are considered to be more communal than men, which means that they will be friendly, unselfish, emotionally expressive and concerned with others. Men on the other hand, are categorized in the agency dimension and are thus expected to be more agentic than women, meaning they will be masterful, assertive, competitive, and dominant in their communication (Eagly, 2009; Spence & Buckner, 2000). In the context of informal interpreting, this might imply that Turkish male informal interpreters will be dominant and assertive and mainly be focused on achieving the targeted treatment for the patient. As for Turkish female informal interpreters, this might imply that they will be friendly and modest in their communication and behavior with the GP and the patient and show more emotions than men. They will mainly be focused on taking care of the patient, stopping the pain, and enhancing their quality of life.
2.3 Interpreters’ roles
The Oxford dictionary defines a role as a part that someone or something has in a particular activity or situation (Oxford, 2014). In psychology the term role is defined as the part played by a person in a particular social setting, influenced by his expectations of what is appropriate (Coleman, 2009). The roles an interpreter can take have been studied by several researchers, and are dependent on whether the particular person is a professional or an informal interpreter.
Informal interpreters often perform several roles during a medical consultation. Besides the obvious role of being a translator of information (i.e. conduit) and the previously discussed role of the life world agent, an often-noticed and prominant role is that of being the patient’s advocate. That is, they often see themselves as acting in the best interest of the patient, empowering, covering and advocating for the patient (Rosenberg et al., 2007, Rosenberg et al., 2008). The role of informal interpreter as an advocate for the patient was also officially recognized by the GP in previous research (Green et al., 2005).
The role of the caretaker of the patient is another role performed by informal interpreters (Rosenberg et al., 2007). Informal interpreters often speak with the patient prior
9
to and after the consultation to ensure adequate diagnosis, treatment and recovery by clarifying patients´ complaints and taking care of the patient and his recovery after the consult.
In addition, many informal interpreters also fulfill the role of mediator, who negotiates the treatment directly with the GP and ensures the recovery of the patient by discussing the ways the GP provides support to the patient. In this role, they also tend to interact on behalf of the patient (Rosenberg et al. 2007).
Another role of the informal interpreter is to fulfill a family role. A study by Green et al. (2005) on the experiences of young immigrant interpreters showed that interpreting for family was a rather natural thing to do. It did not only give them a sense of pride and confidence but it was also highly appreciated by the family. Despite the fact that the interpreting was sometimes experienced as difficult or annoying due to time management or the particular subject of the consultation, most young interpreters still perceived it as an obligation to help, making the fulfillment of the family role also one of the main roles of the informal interpreter (Green et al., 2005; Rosenberg et al., 2008).
Last, informal interpreters may also perform the role of cultural mediator, negotiating and providing explanations of the cultures of patient and GP.
The various roles of the interpreter have been investigated by several studies. However, only a few studies have investigated the perspectives of Turkish informal interpreters about medical consultation in general practice, and no research has been done yet on possible gender differences in informal interpreters’ role perceptions. Research shows that men and women show differences in their motives for performing prosocial behavior. Prosocial behavior refers to behaviors that are seen as beneficial to others, which includes helping and comforting but also sharing, guiding, rescuing and defending others (Eagly, 2009). Hence, interpreting for a relative can be seen as a form of prosocial behavior.
It has been suggested that women are generally more empathetic and sympathetic than men (Monk-Turner, Ciba, Cunningham, 2004; Piliavin & Unger 1985; Underwood & Moore 1982) and that they perform prosocial behavior for relational, altruistic motives. This means that they want to support and care for others and often place the needs of others before their own (Wood & Eagly, 2002). In contrast, males perform prosocial behavior in order to gain prestige or to imply a higher status and more self-focused (i.e. egoistic motives; Wood & Eagly, 2002). These differences in motives for prosocial behavior might imply that male informal interpreters are more likely to perform the role of the advocate or mediator whose gender role encourages heroic forms of interpreting, with egoistic motives of saving
10
the patient from harm (Brunel & Nelson, 2000). As for female informal interpreters, gender differences might imply that they are more likely to perform the role of the life world agent and the caretaker of the patient, due to their altruistic characteristics.
To investigate these assumptions the following sub-question is formulated:
SQ1: What are the perspectives of Turkish informal interpreters regarding their roles during
a medical consultation in general practice and are there differences between men and women in this regard?
2.4 Informal interpreters and the quality of medical communication
Several studies provide evidence for a higher quality of communication in case a professional interpreter is used in a consultation, compared to the absence of an interpreter (Flores, 2005; Rosenberg et al., 2007, Rosenberg et al., 2008). There are also studies that have reported negative influences of an informal interpreter on the quality of the communication (Aranguri et al., 2006; Flores et al., 2003; Twilt, 2007). In her research, Twilt (2007) focuses on the different kind of errors that occur during a medical consultation in case an informal interpreter is involved, by using three categories of content change caused by the informal interpreter: omissions, revisions and reductions. Omission refers to leaving out information by not translating the sentence or phrase that was provided by the GP or the patient. Revision deals with a change made in the information and reduction refers to reducing the information provided by the GP or the patient. Omissions seem to be the most prominent error followed by revisions and reduction. All three kind of errors lead to decreased mutual understanding between the patient and the GP (Twilt, 2007). Aranguri et al. (2006) also reveal negative consequences on the quality of the communication between GP and patient when an informal interpreter is present. Their research revealed that the interpreter was speaking less than expected due to omission followed by revisions and reductions made by the interpreter, which is in alignment with the results of Twilt (2007) and Flores (2003).
Twilt (2007) also refers to side-talk activities where one of the three conversation participants is excluded. This occurs when two of the three participants are in conversation with each other. Informal interpreters seem to have a high tendency to perform side-talks, which in turn causes the GP to be irritated and lose grip on the conversation. The GP often feels that his authority is undermined during side-talks (Twilt, 2007; Rosenberg et al., 2007). In addition, Aranguri et al. (2006) found that in some cases the informal interpreter
11
directly answered questions stated by the GP and did not translate questions aimed at the doctor. By not translating the questions that the GP and patient ask each other, both interlocutors will miss out key information. Another consequence is that the GP will often consider migrant patients as passive and not interested (Davidson, 2000).
There is hardly any research that focuses on the perspective of the informal interpreter regarding their influence on the quality of a medical consultation in general practice and no research has yet focused on possible gender differences. Several studies do however confirm differences between men and women in their communication process (Blum, 1999; Kunkel & Burleson, 1999; Street, 2002; Tannen, 1990). Tannen (1990) states that women communicate to build community and affinity whereas men use talking to establish status and independence. In addition, women seem to have greater aesthetic qualities (i.e. pleasing) but are less dynamic (i.e. strong, active) than men. Women are, compared to men, also considered to be more expressive and accurate at perceiving the emotions of others.
In the context of informal interpreting, this might imply that Turkish male informal interpreters will be more dynamic and mainly focused on achieving the targeted treatment for the patient which will cause them to make more omissions and reductions. As for Turkish female informal interpreters, this might imply that they will be friendly and more expressive in their communication with the GP and the patient causing them to have more side talks, and make more revision errors than male interpreters. In addition, female informal interpreters will more likely show more emotions than men and mainly be focused on taking care of the patient. Considering these differences, the following sub-question is formulated:
SQ2: What are the perspectives of Turkish informal interpreters regarding their influence on the quality of medical communication in general practice and are there differences between men and women in this regard?
12
3 METHOD
In order to achieve a better understanding of the perspectives of male and female interpreters, qualitative research will be conducted. Qualitative research will provide broadly interpretable data, such as the nature, the value and the properties of informal interpreting (Baarda, 1995). An open approach is the most suitable in this study, as it will give the participants space to share their experiences, motives, expectations and perception. This research method will allow the researcher to understand respondents´ perception of their experience as an interpreter (Sofaer, 1999).
3.1 Participants
This study was conducted using semi-structured depth interviews among Turkish-Dutch interpreters of 18 years and above. Turkish-Dutch interpreters were only included in the study if they had interpreted for acquaintances, relatives or family members in general practice at least once over the past year. In total 25 people were asked to participate of which 11 people responded positively. Reasons to not participate were not having interest or time to contribute. Seven female and four male participants, within the age range of 19 to 30 years old, were recruited using a snowballing method (Sofaer, 1999) and were contacted either through phone or social media. The demographical spread of the patients varied and included cities from the Netherlands, such as Amsterdam, Utrecht, Roosendaal, Arnhem and Almelo.
3.2 Procedure
The interviews were held at the participants’ home or public (quiet) places that were familiar to the respondent, and consisted of a dyadic conversation between the respondent and the interviewer. The dyadic conversation and the setting allowed the respondent to feel as comfortable as possible ruling out social desirable answers as far as possible (Sofaer, 1999).
Prior to the conversation participants were informed about their anonymity and were told that they were being interviewed regarding their experiences with interpreting in general practice. The conversations were held in the Dutch language and were audio recorded. The recorded interviews were transcribed verbatim and were analyzed manually on the basis of the themes of the topic list. The duration of the interviews varied from 40 minutes up to an hour. The quotes used in the results section were translated into English.
13
3.3 Topic list
The interviews were guided by a topic list based on relevant theory and consisted of seven themes focusing on different aspects of interpreter-mediated communication (see appendix 1 for the complete topic list). The first two themes dealt with 1. general demographic information of the patient and 2. acculturation. The themes 3. patient-Interpreter relationship and 4. doctor-interpreter relationship explored the perspectives of the interpreters´ relationship with the patient and the doctor. The theme 5. role of the informal interpreter explored the perspectives of the interpreter regarding his/her role within the interpreter-mediated consultation. The themes 6. power and 7. control explored the interpreters’ influence on the quality of the communication. The topic list ends with asking the participant for his or her opinion concerning the interview.
Although a topic list was present to provide guidance, the participants were free to tell their story in their own manner. This was enhanced by addition of several open questions in the topic list that allowed the respondent to partly influence the structure and content of the conversation.
3.4. Data analysis
To analyze the data, the Constant Comparative Analysis was applied, using grounded theory based on deductive data (Boeije, 2002). The CCM was used because it is an analytic procedure to generate theory in a systematic way. The goal is to detect conceptual differences and similarities, to clarify the concrete power of categories and to discover patterns that will lead to developing a theory. This can achieved by categorizing, coding, and defining categories and connecting these categories to one another (Boeije, 2002).
All interviews were reviewed with the two sub- question and the research question in mind. For both of the sub-questions, a number of codes were assigned to the interview notes for each respondent. The five selected themes of the topic list were used as an initial codebook, based on the interview questions. The themes 3. patient-Interpreter relationship and 4. doctor-interpreter relationship and 5. role of the informal interpreter were mainly used to answer and code for the first sub question, where as the themes 6. power and 7. control were used to answer the second sub question. The codes were applied to each interview. The coded data was then analyzed, and patterns within each theme were isolated. These coded data was then organized into two groups; the male and female group. These two groups were then compared to one another focusing on the differences and similarities between the two groups.
14
4 RESULTS
This chapter describes the results that emerged from the interviews. A short description of the sample will be provided, before presenting the results.
4.1 Sample
Eleven Turkish-Dutch respondents participated in this study, seven of them being female and four of them being male. The female group had a mean age of 22 years, ranging from 19 to 26 years. The male group had a mean age of 26 years, the youngest being 22 and the oldest participant being 30 years old. All male respondents and most of the female group (n=5) were born in the Netherlands. The majority of the sample had either enjoyed or was still continuing higher vocational education. Six out of seven female participants and one of the male respondents were students, other participants were employees. The family composition of the home living respondents consisted in most cases of 4 or more people: a mother, a father, and often two or more siblings. Two respondents were married and had their own families and homes.
All participants felt at home in the Netherlands. However, the majority of the group felt more connected with Turkish people than with Dutch people (n=8). Family was very important to all participants. The majority of the female respondents indicated that they did take the interest of the family into account when making personal decisions (n= 6), whereas the majority of the male respondents said they somewhat try to consider the interest of the family when possible (n=3). All of the respondents were Muslim, and considered religion as a very important aspect in their life. However, only two out of the eleven respondents said they actually practiced their faith.
Most participants started interpreting for family members at around 11 years. Both male and female respondents mostly interpreted for their mother (n=8). However, it was more common for female respondents to interpret for other female family members (n=5), than for their fathers (n=2). Three participants mentioned their father not needing an interpreter due to a good language proficiency of the Dutch language.
15
4.2 Informal interpreters´ roles
When the participants were asked which role they mainly preferred, both male and female respondents said they would rather just translate the conversation and thus fulfill the conduit role. However, all participants mentioned and were aware of their role as the advocate of the patient, making this role actually the most prominent one. However, it was noticeable that the participants were acting this role because it was expected and in a certain way demanded by the patient:
“Eh yes, I think mainly translating but also to get her stuff done. She sometimes tells me: I want you to help me to get that medicine for my pain, haha, so she expects me to book results for her”. (Female, 19 years).
On the surface of it, interpreters did not seem to have trouble with patients’ expectations and they even mentioned doing interpreting out of love for their family. However, as the interviews continued, some irritations and confusion were noticed among six of the eleven participants, four of them being female. Participants often mentioned their parents being too stubborn and controlling over the situation when they did not agree with the GP and the proposed treatment. However, even when participants did not agree or condone participants´ behavior, they still advocated for them:
“Yes, I try [to get things done for the patient] but sometimes I just don’t succeed. I don’t have any knowledge of it [the medicine] and then you´re stuck between two fires. The doctor knows what he is talking about, but my father knows what he wants and what he feels, and then you´re just in between them”.
Interviewer: So how did it end up?
“With my mom getting what she wants, haha”. (Female, 22).
Nine respondents, eight of them being female, answered no when they were asked if it was expected of them to mediate during the conversation. However, as the interview continued it was noticeable that both male and female interpreters did mediate for the patient, in particularly for the treatment, the medical prescriptions and appointments. However, there were notable differences between female and male interpreters.
Male informal interpreters seem to take the mediator role in a more serious and conscious matter as they all included themselves in the process and acted as if they were the
16
patient. They also made important decisions without consulting the patient first. Female interpreters were often less assertive, less confrontational and less focused and aware of this role as they would often consult the patient first and discuss the treatment with the GP while including the patient in the process. Men seemed to perform the act of interpreting mainly to achieve the targeted goal of getting a treatment or medicine for the patient in order to stop the suffering, whereas women were more focused on taking care of the patient and getting the right treatment by including him or her in the process. Male interpreters were also more willing to confront the GP and demand a treatment as three of the male participants mentioned coming along with the patient to make sure he or she was going to receive a treatment for the complaints.
“To me, the most important thing is to provide my mom with clear translation, and to find a solution for her, and Ill push if I have too, for a solution. Indeed, I would even go a step further, I will put the doctor under pressure, and I will pull him over his desk if I have too”. (Male, 30).
Female interpreters often fulfilled the role of the caretaker as they showed more sympathy and empathy for the patient and the GP and put the needs of the patient upfront. Five female participants mentioned their attempts to include the patients within the conversation and make them feel comfortable by providing explanations. Female interpreters also often speak with the patient prior to and after the consultation to ensure diagnosis and treatment by clarifying the patients´ complaints. Male interpreters, on the other hand, showed less sympathy for the patient as they provided less explanation prior and after the consultations and were less focused on including the patient within the conversation.
“Eh yes I try to translate everything at that moment, but when I get home I explain a little bit more. I repeat it and go through the conversation again, just to make sure that she understands it”. (Female, 26)
In addition, it seemed that female interpreters also enjoyed the aspects outside the consultation as one of the participants even experienced it as an opportunity to spend time with the patient
17
“Yah, I really like helping my aunt, she´s such a nice lady […]and when we go to the doctor’s appointment, I always go to her house first, we drink some coffee and then we have a nice time on the way there, we talk on the way and after the appointment we always go and do something fun”. (Female, 19).
Most interpreters were not aware of their role as life world agent, as nine of the respondents, four of them being male, answered no to the question when asked whether it was expected from them to translate patients´ feelings to the GP. However, as the interview continued it became clear that all participants were in fact performing this role:
“I think he expects me to give him explanations, and to understand him fully and precisely. To understand everything that goes around in his head and transfer that to the doctor”. (Female, 20).
Although the interpreters unconsciously did perform the role of life world agent, seven participants, four of them being male, were convinced that the patient was able to express his or her feelings on their own and were thus less focused on performing this role:
“He doesn’t [expect him to express the patients’ feelings to the doctor], my dad is not a feelings person”. (Male, 22).
In addition, male interpreters also didn’t seem to regard patients´ feelings as an important aspect within the consultation and saw no reason for this as they thought it would not add any value to the conversation:
“Yah well, she sometimes mentions her feelings saying that this doesn’t feel right, and yes I try to get it across to the doctor but I doubt if it adds any more value”.
Interviewer: Do you think it’s not important?
“Yes, it doesn’t add anything to the conversation, so”. (Male, 30).
In contrast, female interpreters showed more understanding for patient´ feelings as they were taken into consideration when interpreting. During the interview female interpreters often mentioned that they were there to help the patient by making sure that the patient and the GP understood each other and that the GP was aware of the patients´ emotional state.
18
Three female participants mentioned the latter being their most important role within the conversation.
“Yes, I think she expects me to translate her feelings, but she expects it unconsciously, that I would tell the doctor how she feels, and I unconsciously do it for her[…] When she had a problem with her lungs, I told the doctor how it made her feel, and how it affected her mood”. (Female, 20).
The family role was present among all participants. Both male and female interpreters perceived interpreting for family as a rather natural thing to do. However, male respondents often mentioned that they derived satisfaction from interpreting as it gave them a sense of fulfillment and being needed. Female interpreters on the other hand, often mentioned finding it pleasant to help and take care of the patient, so that the patient won’t have to deal with it alone.
“Yes, I like the fact that I can help people […] I even do it [interpreting in public] for strangers […] It gives me a good feeling, a feeling of gratification”. (Male, 30).
“Yes, I like going [to the consultation] with my mom, then she doesn’t have to struggle with explaining what is wrong with her”. (Female, 24).
Both female and male interpreters mentioned in some cases facing difficulties or being irritated during the consultations. This was in most cases due to having difficulties to translate, difficulties with the patient being too demanding and controlling over the situation, and due to the fact that they had to take time off to interpreter. However, informal interpreters still perceived it as an obligation to help their family and were more than ready to do so.
“Hmm I like that I can help my family, but the unpleasant part is that I sometimes have to reschedule my appointments, or I am obligated to make time, but yah, its [interpreting] only once in a while, so I do it for my father with pleasure”. (Male 26).
The role of cultural mediator was almost in all cases denied by the informal interpreters and was not seen as an important aspect of the consultations. Ten participants, four of them
19
being male, said that they did not have to deal with explaining cultural differences within the consultations as nothing could be done with and about these cultural differences.
“Not, that has never occurred. My dad wouldn’t even try [to explain the cultural differences]”.
Interviewer: Why not?
“Just because. Why would it be necessary? It’s about the disease not the culture”. (Female, 22).
4.3 Informal interpreters´ influence on the quality of the communication
Omissions were the most prominent errors that occurred during interpreter-mediated consultations in general practice. All respondents mentioned not translating some words or sentences that were provided by the patient. However, respondents were uncomfortable when this issue was addressed as “leaving out information” and spoke of it rather as reductions or revisions. When asked whether they left out things patients had said, they responded that it was not really leaving out information but rather a revised or reduced version of what the patient had said. They often stated that they translated the sentences in their own, shorter, version using their own vocabulary. They did however claim to translate everything the GP says in its exact way.
“eh yah, I just shorten the easy words, I don’t really skip things just like that, I just make them shorter”. (Female, 22).
One male participant even mentioned withholding the patient of important information to protect the patient’s feelings:
“Sometimes the doctor will say that you only have three months to live and then I say that in a different way, I say that yah it’s incurable and eh if we don’t watch out it’s going to get out of hand. You don’t just kick a man down […] a terminal patient doesn’t have to know that. I know my parents and I know they would break down so yah”. (Male, 30).
Five participants, two of them being male, stated that the patient was not aware of these “reductions and revisions” and thought that everything he or she said was being translated. Other participants said that the patient was aware of this, but did trust the interpreter to do
20
the right thing and handling it the right way. However, two female participants mentioned and acknowledged some irritation and anger from the patient when information was left out. The interpreters however didn’t seem to be bothered by this.
“He [The patient] often tells me: you probably didn’t say this, or he repeats himself telling me to say this or that. He´s kind of suspicious haha”. (Female, 23).
In most cases, reasons for omissions dealt with the parents repeating the same information, or using a lot of words to explain the same thing. Other reasons were time shortage, not feeling like translating everything the patient says and not being able to translate the things the patient says. Difficulties concerning translating medical jargon were mentioned by all participants and were often experienced as unpleasant. Two participants mentioned using sign language when they did not know the Turkish translation of the words. These difficulties often caused irritations among the interpreters. Most informal interpreters did however have a high level of confidence in their translation skills.
In general, all participants were not consciously aware of their influence on the quality of the communication. However, four participants, two of them being male, thought that these “reductions and revisions”, would facilitate the communication. They stated that they were helping the GP by making the conversation more pleasant using easier, shorter and more accessible sentences for the GP to understand.
“It [the conversation] goes faster, goes smoothly, otherwise you´ll be there for hours”. (Male, 22).
Furthermore, a different type of error was also mentioned during the interviews, as six participants, two of them being male, stated that they regularly used more words than stated by the patient, in order to achieve the targeted treatment or understanding of the GP. These additions dealt with using more words to explain the symptoms and the situation of the patient. Participants also mentioned using more words to exaggerate the seriousness of the patients´ situation in order for the doctor to take action. When asked if the patient was aware of these additions, the responses were mixed. In some cases the patient did know about these additions and supported it. In other cases, participants mentioned that the patient was
21
not aware of this, but that they wouldn’t be bothered by it as it is in the best interest of the patient.
“Ehm I do that in situation where I think the doctor is not going to take it seriously. So I just make it [the complaints] stronger”
Interviewer: Can you give an example?
“Yes, by saying that the pain is really too much, for example eh, if she´s not getting any medicine and she does want something for the pain, then I just say that she’s really bothered by it”
Interviewer: So is what you’re saying not true?
“It is indeed true in some way, maybe not so exaggerated but yah I do say it as an extra”. (Female, 22).
There was a difference between male and female interpreters regarding their communication preferences in general practice. All male participants mentioned a preference for a fast and smooth consultation with not a lot of talking. Two of them seemed to avoid side talks and felt uncomfortable when this happened. When asked why they felt uncomfortable, they responded saying that it took a lot of time. In the other cases, participants stated that side talk did not occur. In contrast, with female interpreters side talks were very common and happened in all consultations and were used to explore, discuss and explain the complaints of the patient. Only three female respondents mentioned feeling uncomfortable during side talks. The reason for this was different than for men as female participants felt they were excluding the GP from the conversation.
“She [the mother] sometimes tells me that I do it [translate] too fast and short off, and my sisters they just take the time to explain everything in more detail. I think she likes that more”. (Male, 30).
Furthermore, three male interpreters had a distant relationship with the GP and were defensive and or dominant towards the GP. They often showed dominance and assertiveness within the consultation by directly speaking to the GP, providing advice to the patient and making decisions on behalf of the patient.
22
“It´s [the relationship with the GP] businesslike, and friendly [….] I don’t really have a relationship with her [the GP] haha, It is what it is [....] I am just there to only make things clear”. (Male, 24).
Female interpreters are more connected with the patient and the GP as they were friendlier, more understanding and emotionally expressive during consultations. However, five female participants also mentioned making sure to get the right treatment for the patient, and were willing to confront the GP in order to achieve this.
“At that moment I’m in her shoes and whatever she would say, or push to get, like I want to have that medicine is transferred and expected from me. I have to push for her to get what she wants”. (Female, 20).
23
5 CONCLUSION & DISCUSSION
The results of this study show both commonalities and differences in how female and male informal interpreters perceive their task during medical consultation in general practice and are in alignment with Hofstede´s (1983) femininity-masculinity dimension and Bakan´s (1966) communion and agency dimension.
Both female and male interpreters preferred the role of conduit at first hand, and shared the role of the advocate. In line with recent literature (Rosenberg et al., 2007, Rosenberg et al., 2008), the role of the advocate was the most prominent role performed by all interpreters. However, informal interpreters did not only perform this role out of love for the family (Green et al., 2005), but also to meet patients´ expectations to fulfill this role.
Although male and female interpreters both performed the role of mediator, female interpreters were less aware of this role and less active than male interpreters when performing it. In general, male interpreters were more agentic (Bakan, 1966) and dominant (Hofstede, 1966) within the consultations as they all spoke on behalf of the patient to achieve the targeted goal of getting a treatment or medicine for the patient. Turkish male interpreters are more focused on achieving success and are, unlike female interpreters, less concentrated on the emotional and social aspect of the conversation (Hofstede, 1983). In addition, all male interpreters perceived this role as the most important one within the medical consultation.
As for female interpreters, it was more common for them to fulfill the role of the caretaker. Females often communicate with the patient prior and after the consultation to ensure adequate diagnosis, treatment and recovery by clarifying the patients´ complaints and taking care of the patient and his/her recovery after the consult (Rosenberg et al., 2008). Female informal interpreters are therefore more communal in their interpreting (Bakan, 1966) which allows them to bond with the patient in a more close and dyadic relationship than men. These communal characteristics also make female interpreters better life world agents than male informal interpreters. Female interpreters seem to show more understanding for patient´ feelings, in contrast to men who often didn’t regard the patient’s feelings as an important aspect within the consultation, which is in line with previous discussed literature (Monk-Turner, Ciba, Cunningham, 2004; Piliavin & Unger 1985; Underwood & Moore 1982). Female interpreters often perceived the role of the life world agent as their most important role, while male interpreters were more comfortable fulfilling the mediator role.
24
The family role is fulfilled by both male and female interpreters and is perceived as a rather natural thing to do (Green et al., 2005). However, male respondents often fulfill this role due to egoistic motives as that they derive satisfaction from interpreting giving them a sense of fulfillment and of being needed (Wood & Eagly, 2002). In contrary, female interpreters often performed this role due to their altruism, as they find it pleasant and important to help and take care of the patient (Wood & Eagly, 2002).
As for differences within the perspectives of Turkish informal interpreters regarding their influence on the quality of the medical communication, it seems that both male and female interpreters are somewhat oblivious of their impact on the consultation. Omissions are, in line with Twilt´s (2007) study, the most common errors in interpreter-mediated consultations among both male and female Turkish interpreters. Reasons for these adjustments dealt in most cases with repetitions made by the patient, time shortage and facing difficulties with the medical jargon which was mentioned by all interpreters (Twilt, 2007). In addition to previous research (Twilt, 2007), it was found that informal interpreters do not feel comfortable addressing omissions as leaving out information, but referred to it rather as reductions of revisions. In some cases, informal interpreters are convinced that these reductions and revisions facilitate the communication with the GP, as fewer words are used.
Furthermore, a different type of error is noticed within this study as both female and male interpreters added more words than stated by the patient in order to enhance the seriousness of the complaints. These additions dealt with using more words to explain and highlight the seriousness of the symptoms and the situation in order to influence the GP and achieve the targeted treatment for the patient.
The main difference between male and female interpreters regarding the communication process in general practice, concerns the type of communication style they perform (Blum, 1999; Kunkel & Burleson, 1999; Street, 2002; Tannen, 1990). Men are dynamic, assertive and dominant in their communication, often speaking directly to the GP and making decisions on behalf of the patient (Hofstede, 1983; Tannen, 1990). Male interpreters also have a preference for fast and smooth consultations with little or no side talks. On the other hand, female Turkish interpreters commonly use side talks to explore, discuss and explain the complaints of the patient. In general, female informal interpreters seem more connected with the patient and the GP as they are not only friendlier compared to men, but also more understanding and emotionally expressive during the consultations (Hofstede, 1983; Tannen, 1990; Wood & Eagly, 2002). However, in contrast with previous
25
discussed literature (Hofstede, 1983; Tannen, 1990; Wood & Eagly, 2002), female informal interpreters are also able to show assertiveness and dominance within the consultations, as they were willing to defend the patient and demand the desired treatment for the patient when this was needed.
The purpose of this qualitative research was to generate new hypotheses concerning gender differences within interpreter mediated communication in general practice. To conclude, the findings of this study confirm that there are gender differences concerning both informal interpreters’ role perspectives and style of communication during consultations in general practice. These differences, which in their turn seem to be influenced by interpreters´ cultural (Hofstede, 1983) and gender role beliefs (Bakan, 1966), might have an influence on (the quality of) interpreter mediated consultations. From this, one can generate the hypothesis that (cultural) gender role beliefs do not only influence the quality of interpreter mediated consultation but also strengthen the previously discussed male and female characteristics, causing female interpreters to be more communal with more aesthetic communication qualities and men to be more agentic with a dynamic communication style within the interpreter mediated consultation (Bakan, 1966; Wood & Eagly, 2002; Tannen, 1990). Future research should investigate the above stated hypotheses by, for example, conducting a field experimental. A field experiment will not provide strong causal statements about how gender role beliefs lead to differences in male and female interpreters´ communication in interpreter mediated consultation, but it will provide realism making the results better to generalize (Bordens & Abbott, 2005).
However, this study dealt with some limitations. The result of this study should be considered as tentative due to the small sample size. The targeted amount of participants was set at 20, but was not achieved due to refusals, cancellations and time shortage as this research was conducted in two months time period. In addition, there were less male participants than female participants due to the many refusals of male interpreters. Future research should take this in consideration when recruiting by taking a longer time period to execute the research and attempt to reach a higher amount of participants by perhaps using Turkish community centers. To encourage male (and female) participation, a small incentive can be provided. It is also recommended to use male researchers to conduct the interviews, as this also might encourage male interpreters to participate.
Another limitation concerns the interviews itself. Participants mentioned a repetition of questions, which in most cases caused irritations. Furthermore, due to the duration of the interview (up to an hour), many respondents often started losing interest after 30 minutes,
26
making the interview hard to be worked through. Hence, future research should compose a shortened topic list designed specifically for exploring gender differences in interpreter mediated consultations in general practice.
The results of this study can incite future research to include gender differences into this field in order to enhance the knowledge on this topic from a theoretical perspective. The results can be examined and further investigated in a quantitative research to better explain how gender influences interpreter mediated communication. This can be investigated using a survey which includes quotes that are connected to the several roles and communication errors used in the current topic list. Male and female participants can then indicate the degree of their agreement with the quotes, making it possible to detect gender differences in interpreter mediated communication in general practice. Taking into account that most informal interpreters are not aware of their influence on the quality of the communication, it is also suggested to conduct a non-experimental comparative research, where the effect of gender on the quality of interpreter mediated communication is investigated. Male and female informal interpreters can be observed and or recorded while they´re interpreting in general practice.
In line with the stated conclusions, this study encourage a more gender sensitive approach in interpreter mediated communication in general practice. GPs should keep an open mind in their consultations regarding gender differences among informal interpreters. They need to reflect on the way gender differences may play a role in interpreter mediated communication. GPs´ knowledge and awareness about gender differences and its influence should be enhanced by providing them with the information presented in this study. GPs can then take interpreters´ gender and its influence on the communication in interpreter mediated communication in general practice into consideration, by being aware of the different ways in which male and female informal interpreters perform and communicate during a consultation and stepping in when undesired behavior is being performed.
It is important for the GP to keep in mind that both male and female interpreters are in most cases not aware of their influence on the communication process. Hence, it is suggested to provide the informal interpreter a short explanation of what is expected and desired within the conversation. This can be done prior to the consultation but also, when required, during the consultation. Male informal interpreters can be informed that it is expected from them to give the patient the possibility to speak and decide for him/herself and to take the time to translate not only what the patient is trying to communicate but also what he/she is feeling, as adequate as possible. As for female informal interpreters, who are
27
more common in performing side talk activities during consultations, it is recommended for the GP to step in and ask for translation when this occurs. Such gender sensitive approaches can contribute in improving the quality of interpreter-mediated communication in general practice and enhance the equity in health care provision for the usually underprivileged migrant patients.
28
REFERENCES
Allen, J., & Brock, S. A. (2002). Health care communication using personality type: Patients are different!. London: Routledge.
Angelelli, C. (2004). Medical interpreting and cross-cultural communication. Cambridge: Cambridge University Press.
Aranguri, C., Davidson, B., & Ramirez, R. (2006). Patterns of communication through interpreters: a detailed sociolinguistic analysis. Journal of General Internal Medicine, 21, 623-629.
Baarda, D. B., Goede, d. M. P. M., & Teunissen, J. (1997). Basisboek kwalitatief onderzoek: Praktische handleiding voor het opzetten en uitvoeren van kwalitatief onderzoek. Houten:
Stenfert Kroese.
Bakan, D. (1966). The duality of human existence: an essay on psychology and religion. Chicago: Rand McNally.
Baker, R., Pope, C. & van Royen, P. Qualitative methods in research on healthcare quality. (2002). Quality & Safety in Health Care, 11(2), 148-152.
Basil, D. Z., Ridgway, N. M., & Basil, M. D. (2008). Guilt and giving: A process model of empathy and efficacy. Psychology & Marketing, 25(1), 1-23.
Blum, K. D. (1999). Gender differences in asynchronous learning in higher education: Learning styles, participation barriers and communication patterns. Journal of
Asynchronous Learning Networks, 3(1), 46-66.
Boeije, H. (2002). A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and quantity, 36(4), 391-409.
Bordens, K. S., & Abbott, B. B. (2005).Research and design methods: a process approach (6th ed.). Boston: McGraw-Hill.
29
Brief van de Minister van Volksgezondheid, Welzijn en Sport, mevrouw drs. E.I. Schippers, aan deTweede Kamer der Staten-Generaal, betreffende Invulling subsidietaakstellingen VWS, 25 mei 2011,kenmerk FEZU-3064251.
Brisset, C., Leanza, Y., & Laforest, K. (2013). Working with interpreters in health care: A systematic review and meta-ethnography of qualitative studies. Patient Education and Counseling, 91(2), 131-140.
Burleson, B. R., & Kunkel, A. W. (2006). Revisiting the Different Cultures Thesis: An
Assessment of Sex Differences and Similarities in Supportive Communication. Mahwah, N.J.: Lawrence Erlbaum Associates.
Brunel, F. F., and Nelson, M. R. (2000). Explaining gendered responses to “help-self” and “help-others” charity ad appeals: The mediating role of world-views. Journal of Advertising, 29(3), 15-28.
Centraal Bureau voor de Statistiek. (2013). Bevolking: herkomstgroepering, generatie, geslacht en leeftijd. Retrieved 09 May 2014 from http://statline.cbs.nl/StatWeb/publication
Cohen, S., Moran‐Ellis, J., & Smaje, C. (1999). Children as informal interpreters in GP consultations: pragmatics and ideology. Sociology of Health & Illness, 21(2), 163-186.
Colman, A. M. (2009). A dictionary of psychology. Oxford: University Press.
Davidson, B. (2000). The interpreter as institutional gatekeeper: the social-linguistic role of the interpreters in Spanish-English medical discourse. Journal of Sociolinguistics, 4(3), 379-405.
De Maesschalck, S., Deveugele, M., & Willems, S. (2011). Language, culture and emotions: Exploring ethnic minority patients’ emotional expressions in primary healthcare
30
Eagly, A. H. (2009). The his and hers of prosocial behavior: an examination of the social psychology of gender. American Psychologist, 64(8), 644.
Ferguson, W. J., & Candib, L. M. (2002). Culture, language, and the doctor-patient relationship. FMCH Publications and Presentations, 34 (3), 53-61.
Fiske, S. T., Cuddy, A. J., Glick, P., & Xu, J. (2002). A model of (often mixed) stereotype content: Competence and warmth respectively follow from perceived status and competition. Journal of Personality and Social Psychology, 82(6), 878-902.
Flores, G., Laws, B., Mayo, S., Zuckerman, B., Abreu, M., Medina, L., et al. (2003). Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics, 111, 6-14.
Flores, G. (2005). The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research and Review, 62(3), 255-299.
Green, J., Free, C., & Bhavnani, V. (2005). Translators and mediators: bilingual young people's accounts of their interpreting work in health care. Social Science & Medicine, 60, 2097-2110.
Habermas, J. (1987). The theory of communicative action. Boston: Beacon.
Harmsen, J.A.M. (2003). When cultures meet in medical practice. Dissertation. Rotterdam: Erasmus University Rotterdam.
Hasselkus, B. (1992). The family caregiver as interpreter in the geriatric medical interview. Medical Antropology Quarterly, 6(3), 288-304.
Hofstede, G. (1983). National cultures in four dimensions: A research-based theory of cultural differences among nations. International Studies of Management & Organization, 13(1/2), 46-74.
Hofstede, G. H. (1980). Culture's consequences: international differences in work-related values. Beverly Hills, Calif.: Sage Publications.
31
Hsieh, E. (2006). Conflicts in how interpreters manage their roles in provider-patient interactions. Social Science & Medicine, 62, 721-730.
Hsieh, E. (2007). Interpreters as co-diagnosticians: Overlapping roles and services between providers and interpreters. Social Science & Medicine, 64, 924-937.
Hsieh, E. (2008). ''I am not a robot!'' Interpreters' views of their roles in health care settings. Qualitative Health Research, 18(10), 1367-1383.
Kunkel, A. W., & Burleson, B. R. (1999). Assessing Explanations for Sex Differences in Emotional Support A Test of the Different Cultures and Skill Specialization
Accounts. Human Communication Research, 25(3), 307-340.
Leanza, Y. (2005). Roles of community interpreters in pediatrics as seen by interpreters, physicians and researchers. Interpreting, 7(2), 167-192.
Meeuwesen, L., & Harmsen, H. (2007). Valkuilen in de multiculturele huisartspraktijk: het 'stille' gesprek. Modern Medicine, 2, 34-38.
Meeuwesen, L., & Twilt, S. (2011). "If you don't understand what I mean..." interpreting in health and social care. Utrecht: Centre for Social Policy and Intervention Studies.
Mishler, E. G. (1984). The discourse of medicine: Dialectics of medical interviews. Norwood, N.J.; Ablex Public Corporation.
Monk‐Turner, E., Ciba, P., Cunningham, M., McIntire, P. G., Pollard, M., and Turner, R. (2004). A content analysis of violence in American war movies. Analyses of social issues and public policy, 4(1), 1-11.
Oxford English dictionary online (2014). Oxford English dictionary online. Oxford University Press, Oxford, UK Retrieved 12 June 2014 from http//www. oed. com.
32
Paauw, S. (2011). VWS stopt vergoeding tolken. Retrieved 06 June 2014 from
http://medischcontact.artsennet.nl/archief-6/tijdschriftartikel/97401/vws-stopt-vergoeding-tolken.htm.
Piliavin, J. A., and Unger, R. K. (1985). The helpful but helpless female: Myth or reality. Women, gender and social psychology, 8(5), 149-189.
Robb, N. & Greenhalgh, T. (2006). “You have to cover up the words of the doctor”: The mediation of trust in interpreted consultations in primary care, Journal of Health
Organization and Management, 20(5), 434-455.
Rosenberg, E., Leanza, Y., & Seller, R. (2007). Doctor-patient communication in primary care with an interpreter: Physician perceptions of professional and family interpreters. Patient Education and Counseling, 67, 286-292.
Rosenberg, E., Seller, R., & Leanza, Y. (2008). Trough interpreters' eyes: Comparing roles of professional and family interpreters. Patient Education and Counseling, 70, 87-93
Schouten, B. & Meeuwesen, L. (2006). Cultural differences in medical communication: A review of the literature. Patient Education and Counseling, 64, 21-34.
Schouten, B., Meeuwesen, L., & Harmsen, H. (2008). Wie tolkt er bij de dokter? De praktijk van informele tolken in de gezondheidszorg. Cultuur Migratie Gezondheid, 5(3), 144-151.
Schouten, B. C., Meeuwesen, L., Tromp, F., & Harmsen, H. A. (2007). Cultural diversity in patient participation: the influence of patients’ characteristics and doctors’ communicative behaviour. Patient education and counseling, 67(1), 214-223.
Sofaer, S. (1999). Qualitative Methods: What Are They and Why Use Them?. HSR: Health Services Research, 34(5), 1101-1118.
Spence, J. T., & Buckner, C. E. (2000). Instrumental and expressive traits, trait stereotypes, and sexist attitudes: What do they signify?. Psychology of women quarterly, 24(1), 44-53.
