‘Just scratching the surface’: Miscommunication in Aboriginal health care. 'Just scratching the surface': Miscommunication in Aboriginal health care. ABSTRACT This project used a small number of simulated interactions between non-Aboriginal health professionals and Aboriginal clients to examine communication difficulties that occur in health care. Miscommunication occurred as a result of linguistic, pragmatic and cultural factors. Participants were aware of some, but not all instances of miscommunication. Interpreters were used, along with various other strategies, to try to improve communication. When miscommunication occurs in real interactions it can have serious health, emotional, financial and legal implications. It is concluded that intercultural training and interpreter use are crucial to improving communication between Aboriginal and non-Aboriginal people in health care. 1. INTRODUCTION & AIM Communication difficulties between Aboriginal and non-Aboriginal people are widely recognised by both groups as major barriers to effective access to and delivery of all services, including health. Health statistics for Aboriginal people are frequently described as similar to standards in third world countries (Shannon, 1994, p 33 citing National Aboriginal Health Strategy Working Party, 1989) and 'despite recent improvements, Aboriginal and Torres Strait Islander peoples remain the least healthy identifiable population group in Australia' (Better Health Outcomes for Australians, 1994, p.11). In the Northern Territory, Aboriginal mortality rates are three to four times the non-Aboriginal mortality rates (Territory Health Services Aboriginal Health Policy, 1996). The implications of miscommunication in healthcare are potentially life threatening and costly (National Health Strategy Issues Paper, 1993; Carroll, 1995). Yet there is a paucity of literature focused on the topic of communication between Aboriginal and non-Aboriginal people in the area of health. The literature that does exist consists mostly of literature reviews and theoretical works which are not grounded in data from practise. This project originated from concerns held by several Northern Territory speech pathologists that working directly with Aboriginal people from remote communities without an interpreter or co-worker was not effective. They suspected this was the case not just for them but for all health professionals. It was felt that an interpreter or Aboriginal co-worker would decrease miscommunication between Aboriginal clients and non-Aboriginal workers, and help avoid the consequences of miscommunication. This project was initiated to provide evidence to support establishment of an Aboriginal languages interpreter service and creation of co-worker positions. It was also planned to use examples from the project in pilot training materials, so simulated interactions were used to avoid the issues of confidentiality that would have arisen from using real interactions. The project was intended as a pilot project for a larger, more representative study in the future. This project aimed to address the issue of communication barriers to health care by 1 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. objectively documenting instances of miscommunication using discourse data from simulated interactions between health professionals and Aboriginal clients from remote communities. The project aimed to identify: - linguistic, pragmatic and cultural sources of miscommunication; - positive and negative factors influencing effectiveness of communication; - participants' awareness of miscommunication; - strategies employed by participants to repair or prevent miscommunication 2. FURTHER BACKGROUND Miscommunication can be defined as 'a label for a particular kind of misunderstanding, one that is unintended yet is recognised as a problem by one or more of the persons involved. It can, but does not necessarily lead to dissatisfaction or a breakdown of interaction' (Banks, Gao Ge & Baker, 1991, p 106). It is not simply a difficulty because of dysfluencies or speech errors and does not include intentional deception. If an error occurs but is recognised and repaired, or participants understand each other regardless of errors, then miscommunication has been avoided. Miscommunication can be identified by an observer or participant. Banks et al (1991) state that miscommunication arises from either misstatement (initiated by the speaker/writer) or a misinterpretation (initiated by the hearer/reader) or both. They note that a key feature of miscommunication is that there are social consequences for the interactants, such as misattribution of motives, unwarranted actions, altered interaction patterns and similar responses that can erode relationships over time. Several papers give a broad overview of the impact of cultural and communication factors in Aboriginal healthcare, presenting observations or information drawn from the literature, and applying it to different healthcare contexts such as accident and emergency (Campbell, 1995), obstetrics (O'Connor, 1994), social work (Priestley, 1995) and primary health care (Weeramanthri, 1996), or to general health standards (Shannon, 1994). Other papers have included interview/questionnaire data collected in various contexts: statistics and comments about general practice in Bourke, NSW (Kamien, 1975); interviews of staff and Aboriginal clients of community care centres in Darwin (Jones, 1996); interviews of ten Resident doctors in a rural hospital in northwest Queensland about communication with Aboriginal clients (Mobbs, 1986, 1991); a field study of community health in a remote Northern Territory community (Soong, 1983); and staff questionnaires and interviews with Aboriginal patients on the maternity ward of Royal Darwin Hospital (Watson, 1987). Only one study using an experimental design was located. Steffensen and Colker (1982) had two health care stories (one Western and one traditional Aboriginal) read to two groups of women (American and traditional Aborigines). Results demonstrated the effects of cultural schemata on comprehension of the stories. In other words American women recalled the Western story better and the Aboriginal women recalled the Aboriginal story better. In her study of communication between staff and Aboriginal patients in the maternity ward of Royal Darwin Hospital, Watson (1987) noted three sources of communication difficulty. One source was linguistic difference, particularly regarding time and distance, 2 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. double negative questions, pronouns, lack of semantic equivalents, and differences in the speech sound system of Aboriginal languages compared with English languages. A number of other authors have noted the difficulty relating to quantification. Christie (1985, p 11), referring to Bain’s (1979) work, explains that: all Western notions of quantity - of more and less, of numbers, mathematics, and positivistic thinking - are not only quite irrelevant to the Aboriginal world but contrary to it. When Aborigines see the world, they focus on the qualities and relationships that are apparent, and quantities are irrelevant and (p 21), ‘the whole semantic fields of Aboriginal languages are structured along essentially non-quantifiable and non-scientific lines’. Regarding time, Harris (1990, p 27) reports that ‘rather than focusing on time as a straight line cut up into equal pieces of weeks, months, years, or even centuries, remote Aborigines tend to focus on events’. Eades (1993) makes the point that this is the case not only for traditional-language speakers but also for Aboriginal English speakers. Cooke (1998, pp 48-51) states that for Yolngu, the cyclical aspect of time is more dominant than the linear aspect, and time continues to be expressed with reference to the environment: Yolngu most frequently measure by a process of comparison or reference rather than by enumeration in units of measurement, although not exclusively so: it is quite common to express distances between places in terms of number of nights spent camping whilst travelling between them. Baker, Burke and Green (1998) administered a standardised test of post-traumatic amnesia to 27 non-amnestic Aboriginal adults using interpreters. The expected correct response rate of the test for non-amnestic adults is 100%, but 7 of the 12 questions were answered incorrectly by as many as 63% of the subjects. The authors concluded the results demonstrated the cultural bias of the test, particularly because of the focus on western concepts of time and date. Putsch (1985, p 3345) also describes how time is measured differently in terms of world view and language by different cultures. The lack of equivalents for particular words across languages is a problem that untrained interpreters can not overcome. From a different but relevant context, Putsch (1985, p 3346) gives an example of misinterpretation when a nursing aide (acting as an interpreter) translated ‘Are you allergic to any medications?’ into Navajo as ‘Does the white man’s medicine make you vomit?’ (remember there are other possible allergic reactions). When questioned, she revealed she did not understand the word ‘allergy’ herself. The second major source of communication difficulty noted by Watson (1987) was sociolinguistic difference which includes the use of silence, eye contact, personal names, impersonal debate and direct criticism, reference to death, questioning styles, personal/information orientation and physical approach strategies. As Eckermann et al (1992, p 137, their italics) emphasise, “even when the language is known, tonal differences, colloquialisms, and other factors serve to obscure meaning which can block our access to important cues for responding appropriately’. Also originating in sociolinguistic differences is the phenomenon known as ‘gratuitous 3 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. concurrence’. Walsh (1997, p 19) warns that miscommunication can occur because: In their talk, as well as in Anglo talk, you use words like ‘yes’, ‘OK’, ‘uh huh’ merely to indicate that you are still tuned in. It is not to say: ‘Yes I agree with everything you have said’. It is simply to be polite - in some sense. Diaz-Duque (1982, p 1380) made a similar conclusion, based on a different intercultural context: Health professionals (and interpreters) need to be aware of the quick nod because many of the questions they ask require yes or no answers....even though a patient gives an affirmative nod, he has not really understood much of what was said. The final source of miscommunication was the lack of recognition by staff of different degrees of English language competence amongst Aboriginal patients. To emphasise this point, Watson (pp11-12) cited Connolly (1982, p 26): it is often assumed that patients of non-English speaking origin who have some English skills, understand enough English. This is frequently not the case, and results in patients getting advice, treatment or explanations which they do not fully understand. and Downing (1972, p 1): one of the traps into which we readily fall is to assume from a person's reasonable English that he understands all we tell him. This is not so. He rarely understands all the connecting words which give the language its meaning. Even ordinary words have different meanings in different contexts. Cooke 91998, pp259-269) provides an example of ‘half’ being used differently by Yolngu and Balanda. Diaz-Duque (1982, p 1381) and Sun Butcher (1988, p 53) provide examples of this from other intercultural interactions and Pollak (1984, pp 6-7) explains further that : Even people who seem to speak and understand English fairly well can be out of their depth when faced with complex or distressing situations. Unfamiliar concepts from a language other than our own are often perceived only in their most concrete meaning and this may not be immediately evident. Questions may remain unasked and views or reactions not put forward for fear of appearing ignorant or because the right words to use are not known. Cooke (1998) also comments on the dangers of overestimating a person’s English competency based on fluency at a simple conversational level. Even when people share a similar cultural background and language, and technical jargon is eliminated, one cannot assume comprehension (West and Frankel, 1991, p 180). Insight from an Aboriginal man is given by Lester (1972). He gives his perspective on the difficulties faced by Aboriginal people when they are hospitalised. He gives an example of miscommunication about drug regimes where the nurse 'explained to them (Aboriginal people) in simple English how to take the tablets, how many times a day and when to take them but later she learned the tablets were all taken in one go' (p 6). Lester advocates for cultural education programs for non-Aboriginal people, and employment of Aboriginal health workers and interpreters. 4 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Several government publications have made recommendations addressing communication between Aboriginal people and non-Aboriginal health carer providers (Carroll, 1995; LoBianco, 1987; RCIADIC, 1991; Territory Health Services, 1996). The Royal Commission into Aboriginal Deaths in Custody (1991) recognised that 'effective communication between non-Aboriginal health professionals and (Aboriginal) patients in mainstream services is essential for the successful management of the patient's health problems' (Recommendation 247e) and 'That the non-Aboriginal health professionals who have to serve Aboriginal people who have limited skills in communicating with them in English language should have access to skilled interpreters' (Recommendation 249). The Northern Territory Government Implementation Report on the Recommendations of the RCIADIC (1991, p 2) lists four key elements of best practice in access to services, one of which is 'enhancement of communication including use of interpreters and translation of material in the language of the people concerned'. The Northern Territory Aboriginal Health Policy (1996, pp 12-13) addresses the issue of access to services with three major strategies: Aboriginal cultural awareness training; training of Aboriginal employees and communities about the management, administration, structures and processes of health services; and utilisation of an enhanced translator and interpreter service in Aboriginal languages across Territory Health Services. Other relevant literature can be classified into the following subjects: 2.1 Communication between health professionals and clients in general. 2.2 Communication between health professionals and clients of other cultural or language backgrounds 2.3 Communication between Aboriginal and non-Aboriginal people in general or in other contexts 2.4 General cross-cultural communication / miscommunication 2.1 Communication between health professionals and clients in general. If miscommunication occurs between health professionals and clients who speak the same language, then communication between health professionals and clients when they do not share a language will inevitably be troublesome. West and Frankel (1991) reviewed the literature on miscommunication in medicine, summarising that the earliest work was descriptive (for example, Barnlund, 1976) then explanatory (for example, Boyle, 1970) and then increasingly discourse-based. Of the latter, two studies, Freemon et al (1971) and Korsch, Gozzi and Francis (1968), used the same discourse data - tape recordings of 285 visits to family doctors, with chart review and follow up interviews with patients. They both concluded that doctors were found to talk more but show less emotion than mothers, and that the outcome was favourably influenced by having a physician who 'gave the impression of offering information freely without the patients having to request it or feeling excessively questioned'. Treichler et al (1984, p 78) analysed video recordings of patient-doctor and patient-medical student discourse and concluded that the doctor’s interview and data recording style, and his 5 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. emphasis on biomedical factors 'hindered a full expression of the patient's concerns and development of a mutually agreed upon agenda for the visit', whereas concerns were expressed more readily to the medical student because of his unhurried manner and way of asking for information. McTear and King (1991) attempted to explain miscommunication by analysing the discourse of a speech therapy session with a child with semantic-pragmatic disorder, partly because difficulties are more obvious and frequent in a speech therapy clinical context. The older, non-discourse based work includes findings that compliance is not related to demographic factors so much as to open doctor-patient communication (Davis, 1968, cited by Barber, 1978), and that doctors' and patients' definition of common medical terms often do not coincide (Boyle, 1970). From his interviews of patients, one researcher concluded that doctor-patient communication is often ineffective and we can safely generalise that that the doctors do not speak patient language and much more seriously that they often give little evidence of understanding it. They are not especially friendly, not very good at making the patient comfortable, and generally lack experience at question-asking. The patient generally adjusts to the doctor’s perspective, offering medical terms whenever possible. When the patient cannot do this well, the history is slowed and made less efficient. In short, the general expectation is for the patient to learn doctor talk. (Shuy, 1973, p121, cited by Barber, 1978). 2.2 Communication between health professionals and clients of other cultural or language backgrounds. There are many papers on general cross-cultural issues in healthcare (Barker, 1991; Brink & Saunders, 1976; MacGregor, 1976; Putsch, 1985). Similarly, there are many general works on the rationales for interpreter use, and procedures to employ when working with interpreters (AASH, 1994; Barker, 1991; Diaz-Duque, 1982; Gentile et al, 1996; Grasska & McFarland, 1982; Pollak, 1984; Putsch, 1985; Ramsey, 1984, Sebok, 1984; Tessier, 1984). Similarly there are many papers on general cross-cultural issues in healthcare (Barker, 1991; Brink & Saunders, 1976; MacGregor, 1976; Putsch, 1985). Weaver and Weatherley (1997) give information on where to access interpreters and translators across Australia. Several papers have looked at specific situations in depth and included discourse data. Clark (1997) completed an ethnographic study (audio & video recordings of assessments, interviews and informal discussions, observations in different contexts, documentation) of the ways interpreters and speech pathologists work together during assessment of NESB adults following neurological impairment. She found considerable uncertainty about respective roles, and a need for training for both professions. Launer (1978) worked in an outpatients department in a Nigerian hospital. He recorded and transcribed interactions between English speaking doctors, Hausa speaking clients and the medical orderlies acting as interpreters. He found many problems to do with interpreters paraphrasing or interpreting incorrectly and failing to interpret vital information, asking irrelevant questions, and arguing with patients. He concluded that interpreters need formal training to interpret and doctors must be trained in the use of interpreters. Sun Butcher (1988) observed and documented the assessments of 58 ethnic clients of a Brisbane Aged Care Assessment Service. She emphasised that communication problems 6 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. can occur even when the client is a fluent English-speaker or when a qualified interpreter is used. Both interpreters and health care providers need specialised training, and need to prepare together for each particular case. The literature in this area warns of the dangers of miscommunication for clients who do not share language and/or culture with their health carers. The National Health Strategy Issue Paper (1993) cites several papers which list dangers including unnecessary tests, and inappropriate surgery, medication or therapy (Mc Donald, 1992); taking prescribed drugs without a full knowledge of their purpose or side effects; being hospitalised without knowing the type of medical treatment they were to receive; receiving medical treatment without consent; being mistaken for other hospital patients and receiving inappropriate treatment; being returned home with a serious condition; and undergoing treatment which conflicts with their cultural beliefs (Health Department Victoria, 1991). Additionally, these clients’ basic human rights are at risk and they may be subjected to injustices and/or discriminatory behaviour: ethnic patients experience coercion (in that they unwillingly consent to "health care" which is counter to their needs), oppression (being treated in a manner which is discriminatory and often cruel), and dehumanisation (through being deprived of the respect they should receive). (Johnstone and Kanitsaki, 1990, cited in National Health Strategy Issues Paper Number 6, 1993, p 139). A number of writers have specifically investigated the roles that each partner takes on in health interactions, both within and across cultures. Pauwels (1991, p 85) described how the health professional is in most cases the dominant communication partner, The health professional: initiates, directs, and concludes the interaction with a patient. He or she controls the interaction and the flow and nature of information; selects the relevant bits from the information provided by the patient; initiates changes and concludes topics; and is usually also in control of turntaking....the health professionals dominant role... is a consequence of the fact that interaction between an expert (health professional) and a layperson (patient or other health care user) are unequal encounters...the health professionals role as the more powerful communication partner (in most instances) may be misused to the extent that it has a negative effect on the treatment of the patient or on patient compliance in general. In this study, in the interactions with limited-English speakers without an interpreter, both parties produced fewer speech acts but the numbers of speech acts made by each party was more equitable as the health professionals said proportionately less. This pattern was also noted by Pauwels (1995, p133): There is a tendency for health professionals to ask fewer questions of and to say less to patients who do not speak English than is the case with their English-speaking patients. The results of this avoidance of communication can be serious. Misdiagnosis followed by inappropriate treatment of management can result because the health professional did not obtain the basic patient history. Patient compliance is often also affected because the patient receives limited if any information about what is wrong with him or her. This in turn may lead to unnecessary anxiety in the patient, who is unlikely to take the necessary steps to manage the condition. The lack of communication resulting from health professionals not knowing how to communicate across the language barrier also affects the NES patient’s perception of health care in Australia. Frequently such patients feel discriminated against or lose confidence in the healthcare system because they perceive the health professional’s lack of communication to be a sign of a lack of the necessary skills to treat them adequately or of interest in their problems, or reflective of a belief that their condition is beyond 7 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. medical help. Even when communication partners share the same mother tongue, an imbalance in communication roles occurs. West & Frankel (1991, pp178-184) reviewed the relevant literature (Mishler, 1984; Shuy, 1976; Tannen and Wallat, 1982, 1983) and summarised that ‘physicians use different linguistic registers (ie. forms of talk characterised by distinctive uses of pitch, pace and intensity) to enhance, limit and exclude patients’ participation over the course of medical encounters’. Treichler et al (1991, p 68) cite Frankel’s (forthcoming at the time) and West’s (1983) findings that: speech exchange system in which one party chronically occupies the initiating position and the other party occupies the responding position, it follows that the initiating speaker exerts a form of organisational control over the respondent. This occurs because questions, particularly closed questions, limit what is appropriate to say next. The consequence is that the client’s complaints may be ‘assessed on the basis of incomplete or narrowly defined knowledge’ (Treichler et al, 1991, p 63). Open questions have the potential to share power between partners if the response is listened to. Shuy (1970, pp 130-131) also commented on the imbalance in doctor-patient interactions: Communication is dominated and controlled by the physician as (1) doctors expect patients to adjust their speech to doctor talk; (2) patients begin the medical interview with their very best doctor talk but learn during the interview to talk it better; (3) a great deal of what the doctor says is not understood by the patient; (4) a great deal of what the patient says is not understood by the doctor; (5) the nature of the medical history tends to intimidate clients, even to the extent of offering false information. The recommendations of the National Ethnic Health Policy Conference (1988) included better provision of health interpreters, increased training of interpreters and health professionals, upgrading and/or establishing Government health interpreter services, legislation to ensure the rights of non-English speaking people to accredited health interpreters, and recruitment of more bilingual, bicultural health workers. The participants iterated that non-English speaking people have the right to an appropriate interpreter 'irrespective of time and location and at no direct cost to the individual'. 2.3 Communication between Aboriginal and non-Aboriginal people in general or in other contexts. Bain, 1992; Davidson, 1983; Eades, 1988b & 1991; Walsh, 1997 discuss communication between Aboriginal & non-Aboriginal people in general. Communication in education is discussed by Christie (1985) and Harris (1990) while miscommunication in the legal system is described by Cooke (1991, 1998), Eades (1988a, 1993) and Koch (1991). Communication between Aboriginal and non-Aboriginal people involved with the police and legal system is of obvious concern given the over-representation of Aboriginal people in custody, and the importance of land claims to Aboriginal people. Cooke (1991, 8 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. p 2) concluded that the miscommunication that occurred in a coronial inquest arose from 'any of a number of factors such as linguistic interference between witnesses' first and second languages, non-recognition of nuance or idiom; the use of complex grammar; and other sociolinguistic or cultural factors'. Aboriginal witnesses’ testimony was controlled to different degrees by the forms of questions used by non-Aboriginal counsel (Cooke, 1998). This is consistent with the observations noted above, where patients’ communication is controlled by health workers’ questions. Koch (1991) examined the transcripts of a Aboriginal land claim hearing. He attributed most of the miscommunication that occurred to the fact that the Aboriginal people spoke nonstandard English but that this was not acknowledged and taken into account by the court. Eades (1988a, 1993) also describes miscommunication in the legal system and draws similar conclusions. Nelson (1978), Brennan (1979) and more recently Carroll (1995) presented the case for establishment of Aboriginal languages interpreter services in the Northern Territory and LoBianco (1987) advocated for Aboriginal interpreters nationally. 2.4 General cross-cultural communication / miscommunication. Amongst many other works, Banks et al (1991) defined miscommunication and FitzGerald (1996) examined the spoken discourse of immigrant professionals solving problems in groups. Of the literature cited above, some use discourse to demonstrate their conclusions (Clark, 1997; Cooke, 1991, 1998; Eades, 1988a; FitzGerald, 1996; Freemon, et al 1971; Korsch, et al, 1968; Launer, 1978; McTear & King, 1991; Treichler, 1984). However, none of the literature addressing communication between Aborigines and non-Aborigines in the health area is based on actual discourse. FitzGerald (1996, p 21, paraphrasing Willing, 1992, p 206) found that 'a great deal of the literature on cross-cultural communication provides " broad-perspective sociocultural and cultural-psychological explanations" of what can lead to communication problems, but examples of actual, concrete, detailed interactions are rarely studied or included'. The value of discourse based studies is that: their focus on language and social interaction in the context of actual medical encounters allows researchers to pinpoint communication difficulties as they occur, rather than relying on indirect methods of measurement. This not only affords more detailed understanding of the types of problems that can arise (for example mishearings, misunderstandings, or cases of deliberate deception), it also permits those problems to be tracked and their impact assessed over the course of the encounter. (West and Frankel, 1991, p 184). 3. METHODOLOGY 9 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Simulated interactions between non-Aboriginal health professionals and Aboriginal clients provided the data for this project. Three types of scenarios were played out: a/ Health professional talking with an Aboriginal client with good English. b/ Health professional talking with an Aboriginal client with limited English. c/ Health professional talking with the same Aboriginal client with limited English but with an interpreter. These three scenarios were carried out with two different health professionals, to make a total of six interactions. 3.1 Subjects The subjects who participated in the simulations were: 3.1.1 Two health professionals were recruited through requests for volunteers from a Darwin hospital and rehabilitation service. Both were male, aged in their thirties and forties. One was a physiotherapist, the other a senior doctor at the hospital. The physiotherapist had worked with Aboriginal clients for a total of five years. The doctor had worked with Aboriginal people for 18 years. Both men had completed general and Aboriginal cross-cultural training courses. Both had used interpreters for non-Aboriginal, non-English speaking patients frequently, and had used trained Aboriginal interpreters when available, which was infrequent. 3.1.2 Aboriginal people from remote communities (Yolngu)1 were recruited through direct request by a non-Aboriginal researcher known to them. They were all women in their thirties to fifties. English was at least the third language for all of them, with their first and second languages being varieties of Yolngu Matha (Djambarrpuyngu and Galpu). They were all residing in Darwin at the time of taping the interactions, but all usually lived in north-east Arnhem Land in the Northern Territory. The two 'good' English speakers had learnt English during their education at a missionary school (check about Megan) and at a secondary school in East Arnhem Land. Both had worked as co-workers with health professionals before, doing research and clinical work and presenting at conferences. One had undertaken basic interpreter training and also worked as an interpreter for this project. The two 'limited' English speakers had spent time living in Darwin at different times, so had had considerable contact with non-Aboriginal people. Their proficiency in English was defined as 'good' or 'limited' by the non-Aboriginal researcher who had known them for many years. 3.2 Procedure The interactions were carried out in a small interview room in a rehabilitation centre during a single day. The interactions were videotaped using a digital video camera set up on a tripod. This arrangement meant that there was no need for other people to be present in the room during the interactions. The camera was checked between interactions. The health professional subjects were instructed to take a case history as they would normally do during an initial consultation. The Aboriginal subjects were told to pretend 1 Aboriginal people of Northeast Arnhem Land refer to themselves as Yolngu and to non-Aboriginal people as Balanda 10 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. they were seeking help for a health problem which could be invented totally or could be from their own experience, but they had to be consistent in the problem they described if they were having two interactions. No further direction was given, and the interactions proceeded spontaneously and naturally. In interaction one the client pretended she had a chest infection. The client in interaction two and three described a cardiac problem. In interaction four the client simulated having had a stroke. In interaction five and six, the client presented with difficulties with her limbs, apparently secondary to an accident many years before. As the interactions were simulated and used volunteers, there was minimal risk or inconvenience to them. Participants were paid for their time. Confidentiality of any authentic information given was protected by the normal confidentiality standards of health professionals. Informed consent was obtained through a written consent form. Where the subject's English literacy level was limited, and/or spoken English was poorly understood, the consent form was translated and if necessary, read aloud by an interpreter, and countersigned. All the interactions were transcribed for their English content by the author, with some of the Yolngu Matha content also translated and transcribed by Yolngu Matha-speaking co-workers. 3.3 Analysis Analysis of the taped interactions consisted of: 3.3.1 Descriptive analysis of the videotaped interactions by Yolngu Matha speakers. Three interactions were analysed by a non-Aboriginal linguist, the other three by the two Aboriginal, 'good' English speaking participants. They commented as they watched the videos, with their comments being recorded on audiotape and later transcribed. This allowed in depth, insider comment on particular passages. Once identified, instances of miscommunication were classified by the author as arising from linguistic, cultural or pragmatic differences between Yolngu and Balanda. 3.3.2 Speech act analysis. Using a classification system described by Fey (1986) [which he based on Dore (1979) and Chapman (1981a)], every utterance of the interview was coded, then codes were tallied and tabulated (Appendix C). Coding was done by the author and independently by another experienced speech pathologist. Inter-rater reliability was calculated as between 56.59% and 79.65%, averaging 66.7%. (One rater had not coded non-verbal communication, and had coded according to punctuation rather than content while the other had done the opposite). Differences in coding were resolved through discussion resulting in a final agreement rate of 100%. This method of analysis was chosen as a way of quantifying the data, and summarising interactions as a whole, in comparison to the descriptive analysis where particular instances were isolated for comment. Fey's classification system was designed to describe language impaired children in terms of their communication style, along two continua responsiveness to the needs of the conversational partner, and conversational assertiveness. There is no reason the system could not be applied to adults with 'normal' 11 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. language, and it was thought that this type of analysis could provide further insight into the nature of the interaction between health professional and client. 3.3.3 Debriefing interviews. Following each simulated interaction, the health professional and the interpreter (when applicable) were interviewed by a co-researcher using a standard questionnaire (Appendix D). This interview sought the participants' opinions on the success, or otherwise, of the simulated interactions, their awareness of miscommunication, and the similarity of the simulations to real life interactions. Demographic data and information about the intercultural experience and training of the health professionals were also sought. The study was limited in sample size to allow detailed analysis of the small number of interactions. It is recognised that the findings of the project were limited in their external reliability because of the small sample size in terms of numbers of participants, professions represented, and Aboriginal communities/languages represented, but this project was intended only as a pilot project for a larger, more representative study in the future. Using simulated rather than real interactions was a potential threat to the validity of the findings, but was necessary to protect confidentiality when videotape examples were later used for training. 4. RESULTS 4.1 Descriptive Analysis 4.1.1 Indicators of Miscommunication Miscommunication was suspected when the following conversational features occurred: 4.1.1.1 Responses did not match requests, for example, when a choice question was answered by a yes/no response, or when the question was 'how long' but was answered as if it were 'how often?'. For example, in interaction one between the doctor and the client with good English: 2 Dr: C: And how many days you been taking the Amoxil? I take one, one tablet 3 times a day. 4.1.1.2 An Aboriginal client gave an unconvincing 'yes' response to a direct question (including indirect questions in yes/no form which are intended to elicit extended information but are taken literally and answered with 'yes'). For example, in interaction one: 2 Transcription key Dr - doctor C - client I - interpreter YM - Yolngu Matha (x secs) - pause of x seconds // - overlapping talk 12 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Dr: C: Now this Amoxil, do you know what it does to the infection? Uhhuh. and later: D: C: Do you know about those viruses and germs that cause.. Virus nods 4.1.1.3 Participants stated they had not understood, for example, in interaction two between the doctor and the client with limited English: C: Dr: C: //I'm telling my personal problem you know. Serious. Telling my personal problem I say to you. How do you mean? Myself, you know. Like keeping that, my... Dr: I'm not quite understanding. hand on her chest = 'myself'' 4.1.1.4 Participants asked for clarification, for example, in interaction three between the doctor and the client with limited English, with an interpreter: Dr: I: Dr: Dr: I: C: I: C: I: So during one night how many times does that happen that you, do you go to sleep and wake up short wind, or do you, can't get to sleep because of short wind? Rephrase that question again. I wanna know how many ti, or how quickly it happens, I guess, just, can you get to sleep and then you wake up short wind // or can't you even get to sleep sometimes? //phone rings, Dr answers briefly That's real life, that's how it happens. When you go to see the doctor, the phone rings. Bilanya nhukun nhunu bayiny ngonga bala nakamama bala nhunu bayiny ngoy dup'dupthuna? (When you wake up do you feel any heartbeat?) YM YM silence YM. Can you rephrase that question again? 4.1.1.5 One participant remained silent for some time following a question, for example, in interaction five between the physiotherapist and the client with limited English, with no interpreter: P: C: P: C: I'm a physiotherapist. You're at Rehabilitation. I'm just going to ask you some questions and write them down. Why have you come here? What's wrong with you? How are you sick? (4 sec) Do you, do you have any pain? gestures to his papers silence Do you speak any English? anything? Little bit. 4.1.1.6 Utterances were cut off or finished by the other partner, for example, in interaction two, between the doctor and the client with limited English: 13 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Dr: Has that been going for a long time or just, just last few days? C: Dr: Just, every. Every time you go for a walk. gestures 'long' and 'short' 4.1.1.7 Participants later identified miscommunication (one interpreter was involved in the analysis), for example, in interaction six the word 'antibiotic' was interpreted when the client actually meant a more generic word like 'treatment': C: P: I: P: Nha right dhalnal dhu wikam nhanany. (What right treatment will they give me?) OK. She asks if Rehab can offer her antibiotic to straight her up. What, what, I think that we can probably help you get better if you come to Rehabilitation. For the antibiotics, you probably, well you can see the doctor here and the doctor will decide if you need them or not. We don't, I, the physiotherapist doesn't look at antibiotics. The doctor can. 4.1.1.8 There was heavy reliance on gesture, for example, in interaction five: P: C: P: C: P: C: P: C: P: C: P: Little bit. OK You tell me if you don't understand, so I know, Ok? Do you, do you, do you have any pain anywhere? sore? back pain? head? Yeah. Leg Leg Both of them? Mmm. OK. In your foot as well? OK. Is that good? Yeah. So knee. What about arm? C: P: What about here? Is it pain? P: Do you wanna put that down. pointing to knee points to his foot shakes head points to foot, then gives thumbs up for 'good' point to both knees point to shoulders and elbow looking from cup to table, point to table lifts his left arm she lifts left arm slowly and uses right hand to help Can you lift that arm? Weak. What about that one? pointing to her right arm moves her right arm freely C: P: touches her leg points to knee C: P: touches his back & leg That's alright. 4.1.1.9 There were inconsistencies from one response/statement to another. For example, 14 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. in interaction one the client was inconsistent regarding the dosage of medication she was taking. In interaction two, the client initially said she had no pain, but later stated she had pain when she lifted heavy objects. In interaction five, the client first said she could walk some distance but later this appeared doubtful. 4.1.2 Linguistic sources of miscommunication: 4.1.2.1 Semantics, Terminology With an interpreter, problems can arise when there are no equivalent words in the other language and the interpreter has to explain the idea symbolised by the word (ARDS, 1994, p 16). Without an interpreter, even if there is some shared language, this problem is likely to be insurmountable. In this study, the doctor noted that: as soon as we started with concepts that are not common in Yolngu culture, simple things like time and distance, we were starting to have trouble, we were really struggling with concepts of measurement and understanding of physiology, there was no common background. Difficulties arose with medical terminology, symptomatology, and quantification of time and distance. In some cases, miscommunication was averted by efforts of the participants. 4.1.2.1.1 Medical terms. In a passage discussed above, in interaction six, the interpreter misinterpreted the client's reference to treatment as 'antibiotic'. The physiotherapist was mistakenly led to believe the client thought antibiotics would fix her problem. He explained that physiotherapists do not prescribe medicine. In interaction three, the doctor tried to explain that he could see the client's heart beating. There is no equivalent term for 'heart beating' in Yolngu Matha so the interpreter used a term that means noisy, breathing, or pumping, but did not convey that this is abnormal, possibly because the doctor began talking again before she had finished interpreting: Dr: I: Dr: I: Just while I'm sitting here I can see your heart banging. YM (I am looking at your heart it's nharwul.) A healthy woman like you, no smoking, no drinking, shouldn't see that. That's not right to see that. It should be just quiet heart beat. I think that's telling me that what I'm talking about is right. Your heart's working too hard. YM In interaction two, the doctor referred to a stethoscope as 'that thing' as in 'they listen to the heart with that thing'. In interaction three he said 'those things' and gestured and assumed the interpreter knew what he was talking about: Dr: Scared. Fair enough. So no doctor has ever listened with those things to your heart before? points to ears & then to client The doctor did not assume the client knew about medical tests and procedures. He paraphrased 'ECG' (electrocardiograph) as a 'listening-to-the-heart test'. 15 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. In interaction one, the doctor tried to check the client's understanding of the word 'allergic'. He did not accept her initial answer at face value but still did not get a definite confirmation that she understood: Dr: C: Dr: And in the past, when you've been to see the doctor, have you been allergic to any medicines? shakes head Do you understand what I mean by allergic? Did you have any reaction to it? C: nods 4.1.2.1.2 Symptoms The description of symptoms and pain may vary across cultures. Some of the English words (sharp, stabbing, dull, throbbing, ache, pins and needles, numb, swollen, short of breath, and so on) used to describe symptoms may not have equivalents in other languages or may have other meanings. In interaction two, the doctor asked about swelling, but the client's response did not refer to swelling exactly. After rephrasing the question, the client gave a definite answer: Dr: C: Dr: C: Dr: C: Dr: C: Dr: C: Dr: C: D, do you have any trouble with your ankles, Yeah. Are they getting swollen and sore? Yeah, um, when I young, you know, I'm young, they always slow, this one, both. Slow? No they (2 secs) um (2 secs) cramp every, when I young you know, all the time ay. Cramp is p... Cramp is pain? Yeah pain. Grabbing on? Yes. How about ankles, they can get fat, big and fat? No. gestures to his ankles gestures at lower leg clenches fist In interaction six, description of symptoms interacts with other factors to create a very confusing conversation: P: C: I: P: I: C: I: I: C: I: P: I: P: OK. And what about your knees? When did they start hurting? pointing at his knees Bayinyamiyu lingu(??spelling) rrambangi ganitji ngaya baraka ga bunukumu mandany bunthurryin (same time that I fell down, broke my arm and my knees were cramped). It happens all at once. When you fell out of the tree. Yeah, fell out. -nods Fell out of the tree, the cramp. Bayngu nhunu ga dhakayngana (you didn't feel pain?) ngingy bayangum (yes but no pain) She only feels pins and needles and numb. Oh, ok. Bayngu nhunu ga dhakayngama. (you didn't feel pain) looking at client Does it, does the pain in here stop you walking a long way, or can you still walk a long way? 16 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. C: P: C: I: C: I: C: I: P: I: Bayngu. (no) Can you walk to the shops in Malak , or is it too far? Wangiya dhawuminy nga. (tell the story) Yo bayngu ngaya biyiny dhaka ngama.(yes, I don't feel any pain) ngunhung ngarrunga nhana buyiny ga nha bayiny nhapam happen ma nhunguku . (When you walking you don't feel anything happen?) Banha lingku ngatjilingu ngatjilingu ga bayangun (spelling?) bulum manymak m ?o?a ktha. (spelling) (Long time ago I used to feel pain, but now I don't feel pain no more. I feel well.) It happens all at once get.. cramps and numb. When she starts to walk, she can feel the, YM, how do I say it? When she's walking she can feel it. Feel it in the knee? Yes shakes head shakes head slightly puts cup down 4.1.2.1.3 Concepts of quantity, specifically distance, time (duration, onset, frequency), amount, and age. In interaction one, despite the client's relative proficiency in English, there are numerous examples of miscommunication when the client tried to quantify her responses: Dr: C: How much do you smoke? I guess one cigarette a day. Maybe. covers mouth. point. rub hands This is known to be an inaccurate amount. She may mean one packet a day, or perhaps she is embarrassed to admit the amount she really smokes. In interaction four, there was a temporary misunderstanding about the number of children the client has, but it was cleared up quickly: P: Girl. And how old is your baby? C: Seven months P: Seven months. Ok. Do you have other children? C: I got three girls. ['three other girls' would have been clearer.] P: And where do you live with them? C: I got two girls with my sister on the island and I got two girls with me. P: So you've got four girls. So two of them, you're looking after two of them. In interaction one, a question about duration was answered as if it were a question about frequency: Dr: C: And how may days you been taking the Amoxil? I take one, one tablet three times a day. The doctor could have clarified her enumeration skills by asking her how long the illness had been present and how long the medication has been taken for then comparing the answers. 17 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Later, a question about amount is answered as if it were a question of duration: Dr: C: Two packet and did they say anything about how many you'd have to take? ...few days?? Miscommunication arose when clients tried to place an event in time. While watching the videoed interaction, Cooke remarks that the Yolngu 'way of explaining is to give a sequence of events and stop at the point where the issue you're talking about becomes apparent, which is fine but did the doctor understand it that way?'. In other words, Yolngu place something in time by referring to events, not to the year or their age at the time. The physiotherapist tried to elicit information in this way in interaction five, but did not allow the client enough time to answer initially: P: C: And when was this? When you're a little girl or No, when I still in// P: C: P: C: P: C: //School. No, still, no school, in the bush. In the bush. At island, no school. When you were a young girl then? Yo (yes) young. gesturing with right arm Again in interaction six, the client explained when something happened by referring to events rather than using time terminology as the physiotherapist did: P: C: I: And was that just recently, like just last week or last month, this year, or //long time ago? //long time. Baman yan banka naya yutjuwala nhawi bayanguyan ngaya yothuy mayan marrmanu. (All the way from when I was little when I didn't have children to the present, the fifties to the eighties) She was bout, in her, it happens long time but. It was happening when she was about thirty, in her thirties. Similarly, in interaction two, both participants agreed the cardiac condition began a long time ago but the doctor thought that she meant when her sons grew up whereas she meant when they were born:?? Dr: C: Dr: C: Did it happen last year? Year before? or just, just last week? When I had my two boys, and then after, when they grow up my two boys, and then started, my heart problem. So for a long time now? Yeah, long time. gestures big stomach It is well recognised that 'traditional' Aboriginal people have difficulty establishing age accurately (Baker, Burke & Green, 1998). The client in interaction two had to estimate her age: Dr: How old are you now? 18 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. C: Dr: C: Dr: C: Dr: Maybe 49, 49 40? 9. 49. beeper goes off 40 or 49. Non smoking, non drinking. Should be still strong, shouldn't have that sort of problem. Despite the health professionals’ recognition that distance is expressed differently interculturally and trying to use concrete reference (rather than using distance terms like 'kilometres', 'miles' or 'feet'), miscommunication still occurred. In interaction two, the client was not given enough time to explain in her own terms. The doctor picked up some cues from her, proposed what he thought she was trying to say, and she agreed. The problem with this process is that an Aboriginal person will almost certainly agree regardless of what is proposed (Cooke, descriptive analysis): Dr: D, how, how far can you walk, how long before you get short wind? C: (5 sec) Walk (8sec) [She was about to go on but he interrupts.] Dr: W, when you're in, in the house, around the home, walking round the home, Ok then? C: Lifting up something very heavy, heavy thing. Dr: Right, you start getting it then. How about if you want to go to that Casuarina shop. Do you know where they are? Long way. If you walked there would you get short wind? C: Yes Dr: How about if you just walked over to that wall over there, would you get short wind? C: Yeah. gestures after pause gestures lifting points nods nods In interaction five, the physiotherapist had asked the client if she could walk a long way to which she responded affirmatively, but later she did not respond as clearly. She referred back to her Arnhem Land home although she had been asked about her Darwin home: P: C: OK. When you're living there, can you walk a long way? Can you walk down to the shop, or is it too far? Home island. And I start walking. Later in interaction six the physiotherapist tried to use the interpreter to help clarify this point, but it was still not clear whether the client had pain when walking and how far she could walk: P: C: P: C: I: C: I: Does it, does the pain in here stop you walking a long way, or can you still walk a long way? Bayngu. (no) Can you walk to the shops in Malak , or is it too far? Wangiya dhawuminynga. (tell the story) Yo bayngu ngaya biyiny dhakangama.(yes, I don't feel any pain) (literally yes I don't feel) ngunhung ngarrunga nhana buyiny ga nha bayiny nhapam happen 19 shakes head shakes head slightly ‘Just scratching the surface’: Miscommunication in Aboriginal health care. C: I: P: I: ma nhunguku . (When you walking you don't feel anything happen?) Banha lingku ngatjilingu ngatjilingu ga bayungun bulum manymak m ?o?a ktha. (spelling) (Long time ago I used to feel pain, but now I don't feel pain no more. I feel well.) It happens all at once get.. cramps and numb. When she starts to walk, can she feel the, YM how do I say it? When she's walking she can feel it. Feel it in the knee? Yes. puts cup down 4.2.2 Syntax 4.2.2.1 When questions switch rapidly from past to future, a limited English speaker is likely to have difficulty. In interaction five, the client heard 'better' and thought the physiotherapist had asked how she got better immediately after the accident: P: C: P: C: So if you're coming in to Rehabilitation and do some exercises, what do you want to get better? What things do you want to do? Do you want to be able to walk a long way? After that when I accident and fall had Aboriginal medicine you know, and then make sand with hot you know. Hot, oh yeah. That's why straight up again, get better. 4.2.2.2 Another potential source of miscommunication related to the structure of language, is the use of questions in the negative form. There was at least one instance of this, in interaction three, although an interpreter was used and may have been able to rephrase the question into the positive form. The answer may be accurate, but this seems unlikely: Dr: I: C: Scared. Fair enough. So no doctor has ever listened with those things to your heart before? YM - points to ears & then to client shakes head 4.1.3 Cultural sources of miscommunication The effects of cultural mismatch were decreased to some extent by the Aboriginal participants’ familiarity with non-Aboriginal culture, through time spent in Darwin, or employment with non-Aboriginal people, and similarly by the non-Aboriginal participants experience of working regularly with Aboriginal people. 4.1.3.1 Verbal confrontation Aboriginal communication is characterised by maintenance of verbal agreement and goodwill, particularly with non-Aboriginal people. Therefore they tend to answer 'yes' without real agreement, that is, they use 'gratuitous concurrence' (ARDS, 1994, p 18-19; Cooke, 1991, 1998; Eades, 1991, 1993; Harris, 1984; Walsh , 1997). There are several examples of this in these interactions - two instances occur in interaction two: 20 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Dr: Has that been going for a long time or just, just last few days? C: Dr: C: Just, every... Every time you go for a walk. Yeah, every time. gestures ‘long’ and ‘short’ and later: Dr: C: Dr: C: Dr: Right, you start getting it then. How about if you want to go to that Casuarina shop. Do you know where they are? Long way. If you walked there would you get short wind? Yes How about if you just walked over to that wall over there, would you get short wind? Yeah. Even then. points nods nod The doctor seems to doubt the last response but appears to accept it regardless. 4.1.3.2 Perceptions of health and illness Steffensen and Colker's study (1982) showed how different world views affect recall of information. Cooke (1990, p 25) describes how 'fundamentally different Aboriginal and Western cultural perspectives on sickness and health' caused miscommunication when an Aboriginal man 'could not accept the (common) Western compartmentalisation of the being into independent mental and physical entities' and the non-Aboriginal lawyer who was questioning him could not accept his refusal to separate the mind and body into distinct parts. Curry (1998) notes that ‘health’ is a concept which appears to generate significant cross-cultural misunderstanding and that the Aboriginal holistic view ‘may contrast quite sharply with Western interpretations which tend to compartmentalise the concept into the world of disease and illness, doctors and nurses’. This can have profound and negative impacts of service delivery. In interactions five and six between the physiotherapist and the limited-English speaker, the physiotherapist recognised that there were 'some cultural aspects to her pain or illness, which came out more with the interpreter - saying how she was scared how she injured her arm would go to her heart': P: I: C: OK. First I ....... with your arm. You said you had a broken arm. What's wrong with it now? Nha nhan ga mangutji rakaraman bunthurr yinyarami nhanu dhu? (with your numbness what do you think is really wrong? What symptoms do you have?) Nhapan buthurryanjaram ngirnganiny walak bili ngaya ngalthum dharpali bala galkinan (When I get numb and I have asthma, I think maybe it's because I climbed up the tree and fell on the ground.) nguthal rununga Baman batha ngaya yutjumala bayngu yothu maddany balanymiyu batha. (Long time ago when I was a little girl on the island before I had my children.) 21 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. I: She said I'm afraid it might effect my heart, or whole of my body, when she fell off the tree. In interaction one, the doctor recognised that the client may have different ideas about the cause of her chest infection, so tried to assess her knowledge of germ theory, the actions of antibiotics, and the effects of smoking. 4.1.3.3 Experience and knowledge of the Western health system The unfamiliarity, or assumed unfamiliarity, of Aboriginal people with the medical system, including the delineation between surgeons and physicians, and the different roles of physiotherapists, doctors, speech pathologists and others. In interaction three, the doctor tries to explain that he is a surgeon, not a physician, which may have led the client to believe she was to have surgery: That problem you've got, because I do, um, just the surgery and cutting operation... not for you! Because I'm that sort of doctor, I'm not so good at this anymore, but there's other doctors who are very good at that. Maybe they can help. It's quite easy sometimes, just with tablets to fix it up. I don't think it's a cutting operation sort of thing. Uncertainty about the level of shared knowledge of anatomy, physiology resulted in the health professionals trying to avoid jargon, but perhaps simplifying things too much, as the doctor remarked about interaction one. Non-Aboriginal people may be unaware how little access there is and has been to Western medical care and education in some remote Aboriginal communities and homelands. In interaction six, the physiotherapist assumed the client had access to Western treatment for her broken arm, but at the time there was no health clinic or services where she lived and the arm was treated with traditional medicine. Similarly in interaction five, he wrongly assumed there was a school where she lived. 4.1.4 Pragmatic sources of miscommunication 4.1.4.1 Silence / response patterns Non-Aboriginal people are less tolerant of silence during a conversation than are Aboriginal people. In Aboriginal discourse, there is no obligation to keep a conversation going or provide responses immediately (ARDS, 1994, p 11; Eades, 1993; Eckermann et al, 1992, p 139; Harris, 1984, p 157; Walsh, 1997). Harris (1984, p 157) provides several reasons for this: Yolngu have less interest in information that has little personal relevance to them; they prefer time to think before responding; they resist pressure to be specific; they rarely verbally speculate on other people’s reasons for doing things. Also, different people have different rights to hold and share knowledge (Walsh, 1994). Additionally, when questions are put to an Aboriginal person in English, which is their third or fourth language, it is only natural that they require more time to process the questions and formulate responses. In this project, the result was that the Balanda health professionals tried to anticipate Yolngu responses and finish utterances for them, or ask another question. In interaction five, the interview has just started and the physiotherapist immediately asks three open questions, pauses for a few seconds and gets no response. Presumably he 22 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. thinks she can't answer those questions so asks a yes/no question. When this does not elicit a response within ? seconds he questions her understanding of English. He does not allow the client time to process the questions and then formulate her response: P: C: P: C: P: C: Hello D, my name is P. Yeah I know. I'm a physiotherapist. You're at Rehabilitation. I'm just going to ask you some questions and write them down. Why have you come here? What's wrong with you? How are you sick? (4 sec) Do you, do you have any pain? refers to his papers silence Do you speak any English? anything? little bit. 4.1.4.2 Information sharing Aboriginal and non-Aboriginal people are known to have different ways of exchanging information (Eades, 1988b, 1991, 1993; Cooke, 1998). Some of these differences are to do with directness. Non-Aboriginal people often use direct personal questions, especially in healthcare situations. Aboriginal people across Australia, whether speaking traditional languages or Aboriginal English, use a variety of indirect methods to gain information, for instance, making a statement and waiting for the listener to agree or disagree, or share relevant information, or telling others what they need to know and waiting for a response at another time (Eades, 1993, pp185-186). This difference in techniques can result in communication problems, as in the example above, when the physiotherapist started the interview with the non-fluent English speaker using many direct questions. Other difficulties arise from the actual form of question used. Responses to yes/no questions are less reliable than information given in the client’s own words because a yes/no response does not require any demonstration of understanding the question (Cooke, 1991, p 4). In interaction five, a simple affirmative response is given, but later in the same interaction, and later in the next interaction with an interpreter, it is unclear whether she really can walk a long way: P: C: No. With your sore knees, can you walk a long way? Yeah. Choice questions can also be problematic (Eades, 1993). For example, in interaction six, two choice questions were used, and met with ‘no’ responses. It is unclear which choice the client is saying ‘no’ to, or in fact, if she is indicating incomprehension of the question: P: C: P: C: Does it, does the pain in here stop you walking a long way, or can you still walk a long way? Bayngu. (no) Can you walk to the shops in Malak , or is it too far? - shakes head shakes head slightly Simple choice questions can be useful as they avoid the simple concurrence response: Dr: C: Breathing or the heart? Heart. touches his chest gestures 'fluttering' 23 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 4.1.4.3 Paralinguistics Eye contact, facial expression, personal space, tone of voice, and gesture can have a different meaning in different cultures. Direct eye contact, for example, is interpreted by Aboriginal people as threatening and rude, whereas lack of eye contact implies rudeness, evasion or dishonesty to most European-background Australians (Eades, 1993). Eckermann et al (1992, p 138) state 'the unspoken messages given and received in Aboriginal cultures probably have the greatest impact on communication and hence potential rapport between health workers and clients'. In interaction five, the physiotherapist used a thumbs up gesture to mean 'good' assuming the client understood it the same way. The doctor described how his limited-English client has actually adapted to non-Aboriginal ways by using eye contact and less silence, but in 'many other circumstances with a shyer woman particularly, you don't get any of that feedback at all, you just get eyes to the ground and I'm not sure what's happening at all.' 4.1.4.4 Conversational repair / clarification and comprehension-checking strategies. By asking the client to give the information in her own words the interpreter used a good strategy to attempt communication repair: I: Wangiya dhawuminynga. (tell the story) Simply telling people with limited English competence ‘tell me if you don’t understand’ is not enough. The doctor attempted to check comprehension proactively by asking the better English speaker to display her understanding. In the speech act analysis, these requests were coded as 'requests to display knowledge' (RQDI). 4.2 Speech Act Analysis There was obvious imbalance between the professionals' and the clients' utterances. The health professionals' conversational style was more assertive: average utterance length was longer, they used more assertive comments and statements, and requests were more frequent that responses. The clients’ conversational style was less assertive, with shorter utterance length, high use of responsives, and few requests, or assertive comments and statements. In the interactions with limited-English speakers, there was more equity simply in terms of numbers of speech acts. The interpreter used a more even spread of assertives, requests and responsive speech acts as she spoke for both parties as well as for herself. Despite frequent threats of miscommunication, speech acts continued to occur in adjacent pairs (for example, a request for information was followed by a response that attempted to be informative, a request for clarification was followed by a clarifying response, a response or an assertive was followed by an acknowledgement, and so on). In other words, both partners continued to try to communicate, and to try to be responsive to each other. 4.3 Feedback interviews 24 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 4.3.1 Participants' Awareness of Miscommunication Some instances of miscommunication were overt and recognised by at least one participant at the time, but others remained unrecognised by the participants. These unrecognised instances of miscommunications are of greater concern, as they cannot be repaired if participants are unaware of them, and decisions or opinions may be based on the misinformation that occurs. In the first interaction, the doctor stated that problems 'sometimes' occurred. He was alerted to miscommunication when there was a mismatch between questions and answers. In her feedback, the client denied any communication problems, with either the simulated interaction or real interaction at the Aboriginal medical service. This denial may be in itself an instance of miscommunication. She was possibly denying problems to avoid conflict. Alternatively, the way she was asked about miscommunication could have elicited a response that appeared she was denying problems when this is not actually the case. In interactions two and three, the doctor stated communication problems occurred 'often' and he could tell by the client's facial expression, and delayed responses. 'I think she was struggling throughout the whole thing to get it right and vice versa. I was struggling to understand her'. The interpreter in interaction three identified questions to do with number concepts as being difficult, for example, 'how far?' 'how many', 'how long'. She also noted that she needed to interpret the doctor's message about talking in Yolngu Matha for the client. After that communication was easier. In other words she had to explain to the client how interpreters work because the client had no prior experience with interpreters. In interaction four, the physiotherapist thought communication problems occurred 'rarely'. He identified problems by observing that the client was 'fishing for an answer'. The physiotherapist reported that communication problems occurred a 'couple of times' in interaction five and 'more' in interaction six. He realised problems had occurred when the client's response was a blank look or silence. Establishing the source of the problem was 'just a guess' without an interpreter, but he was able to get more feedback with an interpreter. 4.3.2 Strategies Used to Prevent or Repair Miscommunication 4.3.2.1 With the good English speaker In his feedback, the doctor reported he was not conscious of using strategies during the interactions but later recognised that he had used more generic terms, or less precise medical terms to try to ease communication. He felt this may have actually complicated things as he may have underestimated the client’s knowledge and could have used more precise terms. He felt this problem was less likely to occur when working in remote communities because one gets to know people and know the extent of their knowledge of 25 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. the Western health system. The physiotherapist asked which name the client preferred to be called, which he felt was 'a way of getting her on side'. He was unsure whether he should make direct eye contact, so monitored the client's reaction as he looked at her. When she did not avert her eyes, he assumed she was comfortable with eye contact and continued to use it. 4.3.2.2 With the limited English speaker The doctor rephrased his questions and used concrete examples where possible. The physiotherapist asked the client to do some actions by modelling the actions himself. Occasionally the health professionals finished a phrase for the clients. They may have done it unconsciously or may have thought it was a useful strategy. 4.3.2.3 With interpreter When it was apparent to him that there had been a miscommunication, the doctor stated he retreated and paraphrased and used concrete examples (for instance, when trying to find out the distance the client could walk) although he still was not always sure he had the correct information. The physiotherapist was conscious of directing his communication to the client rather than to the interpreter, and stated he had learnt this in his training. He also stated he allowed extra time for responses, and asked some of the same questions in different ways to make sure they had all understood each other. The strategies used by the interpreter were asking the doctor to rephrase hard questions, and, although not acknowledged, asking the client to tell the story in her own words. 4.3.3 Factors Influencing Communication As identified by the non-Aboriginal participants, the factors influencing communication negatively included the time limitations, as it took some time just getting to know the clients' level of English and understanding of medical concepts. The health professionals felt there was not enough time to encourage the clients to ask questions. Lack of shared terminology for time, distance and medical concepts was also specified as a negative factor. Positive factors included the clients' relatively good English, and 'openness' or readiness to communicate, give feedback and persist when communication was difficult. The doctor stated the atmosphere was even easier with an interpreter just by having a third person, possibly because the interpreter and client were both women. He also felt able to use more specific medical terminology when the interpreter was used. 5. DISCUSSION Despite each participant continuing to try to communicate, and try to be responsive to each other, there were frequent threats of miscommunication in the interactions of this study. As Walsh (1997, abstract) states, 'encounters between Aboriginal and other Australians too often create discomfort despite good will on both sides'. Koch (1985, 26 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 1991) also found that miscommunication was frequent despite both sides trying to accommodate the other. In this study’s interactions miscommunication or risks of miscommunication occurred as a result of several interacting factors - linguistic, and cultural / pragmatic. 5.1 Sources of Miscommunication 5.1.1 Linguistic Sources of Miscommunication Semantics (medical terminology, symptomatology and quantification) and syntax were areas of difficulty in the interactions studied here. Predictably medical jargon (including words like 'allergic', 'stethoscope', and 'EEG') was problematic. With her limited training and irregular practice, the interpreter used in this study was not able to overcome this issue. In this study, problems arose even when a client appeared to have reasonable English, and the health worker tried to avoid jargon, explain in lay terms, use gesture and check comprehension. This was because even ordinary words can have several meanings depending on the semantic and syntactic context, and underlying cultural differences. Information related to time, dates, distance, and amount was difficult to ascertain regardless of whether an interpreter was used. 5.1.2 Cultural and Pragmatic Sources of Miscommunication The effects of cultural mismatch were decreased to some extent by the Aboriginal participants familiarity with non-Aboriginal culture, through time spent in Darwin, or employment with non-Aboriginal people, and similarly by the non-Aboriginal participants experience of working regularly with Aboriginal people. Even so, miscommunication arising from cultural / pragmatic differences still occurred. The phenomenon of gratuitous concurrence was noted several times. 5.1.3 Imbalance Between Communication Roles The results of the speech act analysis agree with previous reports on the styles of communication adopted by patients and health professionals. Clearly the imbalance of power which always exists between patients and health workers (but is more marked between white professionals and Aboriginal people) does strongly influence trust and interactions. (Eckermann et al, 1992, p 140). 5.1.4 Difficulties With the Use of Interpreters The situation with Aboriginal language interpreting is contrary to the general rule that 'the longer a cultural group has been in Australia, the greater the likelihood that tertiary level courses of study will be developed and interpreter training programs offered in the language of that cultural group' (Clark, 1997, p 29). Due to the lack of an Aboriginal languages interpreter service in the Top End, trained interpreters get very little practise (with paid, recognised interpreting at least). There is no high level interpreter training for Aboriginal languages (Batchelor College, Katherine Region Aboriginal Languages Centre and Institute for Aboriginal Development have trained only to the NAATI Paraprofessional Level, but the minimum recommended level for health interpreting is 27 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. Professional Level). Clients, both Aboriginal patients and non-Aboriginal health carers, also have very little practise at using interpreters. Therefore problems arise. In these simulated interactions the following problems were observed: The interpreter did not prepare both parties as to her role and appropriate procedures to follow. The health professionals similarly did not brief the interpreter as to the purpose of the interview. Clark (1997, p 31) states that 'the overall effectiveness of interpreting is enhanced when (amongst other things) the interpreter has prior notification of the types of resources to be used in the assessment... and a clear understanding of the aims of the session'. So in this context, the physiotherapist could have allowed the interpreter to see his 'initial interview questionnaire' in advance. In his feedback, the physiotherapist stated that he would have chatted with the interpreter beforehand to assess her understanding of medical terminology. The interpreter did not interpret everything both ways, some utterances were not interpreted at all, some were summarised (for example interaction six 'it happens all at once'). The interpreter alternated between use of first and third person. That is, sometimes she would interpret directly using first person pronouns (I, me, mine, my) asinterpreters usually do, but sometimes she would paraphrase and use third person pronouns (she, he, him, her, his, hers). The interpreter was unsure of how to phrase particular concepts, for example treatment/antibiotics. One client was unfamiliar with the use of an interpreter, so continued to try to use English. Sun Butcher (1988, p 47) also observed this and said 'it was as if she believed that speaking directly to the case manager and Community Health nurse even in poor English, would make them understand her problems better'. As the interpreter was related to the clients, she sometimes spoke as a relative with background knowledge rather than letting the client speak for herself 5.2 Potential Consequences of Miscommunication The implications of the miscommunication that occurred in this data can be classified as health / medical, legal, financial and emotional / attitudinal implications. 5.2.1 Health and Medical Implications One very serious consequence of miscommunication here was potential misdiagnosis, or inability to diagnose the patient’s condition. In interaction two and three there is uncertainty about the source of the problem (the heart or breathing), the duration of the problem, the frequency of it, and how debilitating the problem is in terms of how far the patient can walk. The doctor admitted 'I still wasn't sure how severe the problem was'. In interaction five it was difficult to establish the client's presenting complaint, as the physiotherapist said in his feedback: There were lots of difficult issues. This was just scratching the surface. I could only get a superficial understanding if there was a problem, but who knows what the real problem was? She seemed to indicate she'd broken her arm. I knew she hadn't seen a doctor and she'd had traditional medicine, but what exactly happened? I had no idea without the interpreter what she wanted to get 28 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. out of coming. With the interpreter she could say what she wanted. With the interpreter I found out more about what was wrong with her arms and knees and more about what had happened and also found out about thinking and memory which I had no idea about without the interpreter. The lack of a common language between patient and health professional can have serious implication for their communication, for diagnostic accuracy and overall quality of care. It can inhibit describing symptoms effectively, asking questions and talking about fears and anxieties leading to further distress, dissatisfaction with care, and to adverse health outcomes for patients and their families. (National Health Strategies Issues Paper, no. 6, 1993) Other consequences were related to treatment. In interaction one, the client was inconsistent in reporting her medication regime which could indicate she was taking it inappropriately. In interaction four, the health professional would not have been able to decide if a rehabilitation program was appropriate for the client as limited information was obtained about the nature of the client's problem and her goals for therapy. another consequence of miscommunication here was that it was difficult to gauge the client’s understanding of her own condition and its causes as, for instance, the physiotherapist said of the limited English speaker: there were some cultural aspects to her pain, or illness, which came out more with the interpreter, saying how she was scared how she injured her arm would go to her heart... there was a lot more there that I had no idea about the first time. 5.2.2 Emotional and Attitudinal Implications Miscommunication in these interactions potentially caused the following emotional states or attitudes: Fear on the part of the client, if the client in interaction two and three left thinking she has to have surgery. Misjudgement of the client’s understanding of the medical system, for example, the 'antibiotic'-'treatment' misinterpretation makes the client appear as if she does not understand that physiotherapists can't prescribe medicine, and that she thinks antibiotics will cure her physical problems. Discomfort experienced by both parties could discourage future interactions. As Eckermann et al (1992, p140) warn, professionals may use their power (deliberately or not) to conceal their insecurity about their lack of cross cultural social skills. This can lead patients to avoid seeking help when they need it. Silence in response to questions can be ‘interpreted as evasion, ignorance, confusion, insolence, or even guilt’ (Eades, 1993, p 187). 5.2.3 Legal Implications The hospital, health service or individual health professionals could have legal action taken against them if inaccurate diagnosis, lack of informed consent, inappropriate treatment and unresolved illness result from miscommunication. legislation does not recognise interpreters are essential to adequate health care. In spite of the lack of statutory provisions, anti-discrimination laws could provide a legal framework to compel services to provide language services. This has not yet been put to the test (National Health Strategies Issues Paper, no. 6, 1993, p 9). 29 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 5.2.4 Financial implications Hospitals, health departments, medical services, or individual health professionals face increasing costs from longer or unnecessary hospitalisations, inappropriate tests and treatment, and potential legal actions resulting from miscommunication. 5.3 Limitations of this project The findings of this project are limited by several caveats. Firstly, the data are from simulated interactions. Although in several of the interactions the clients discussed real problems, being simulated may have made communication easier in that there was less stress for clients than usual when talking about real problems. On the other hand, it may have made it difficult to elaborate on the symptoms if they tried to act out a condition they had little experience with. The doctor felt less pressured about time then usual. The participants may have taken their role less seriously knowing the interaction was not real. They may have persevered less with their communication and not done all they normally would do to make the interaction work. For instance, the physiotherapist said he would usually take longer to establish rapport with a client, and might do this outside on the verandah. He would also have talked with the interpreter beforehand to assess her understanding of medical terminology and the purpose of the interview. The interpreter may have briefed the other participants on her role and the procedures to follow when using an interpreter. Conversely, they may have performed better knowing they were under scrutiny. There were also the realistic interruptions of pagers and phones. Secondly, although the interpreter was an official trained interpreter, she also happened to be related to the clients, so there was potential interference between her role as an interpreter and her role as a family member. There was also role conflict in that the relationship between one client and the interpreter is usually one of elder sister to younger sister, so the usual power balance was reversed. The participants were in no way a random sample or representative of the normal client / service provider population. The communication in these interactions should have been more positive than usual because these staff have spent lot of time working with remote area Aboriginal clients, and these 'clients' have spent lot of time in town in contact with Balanda, several having worked in co-worker relationships with Balanda health staff. They had a greater awareness of their own 'problems' and the 'system' and were more comfortable interacting with non-Aboriginal men than the average Yolngu woman. Participants had some knowledge of the aims of the project and this may have affected their behaviour. 6. RECOMMENDATIONS The following recommendations for improving communication between Aboriginal and non-Aboriginal people in health interactions are made based on this project and recommendations found in the literature. 30 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 6.1 Establishment of a professional interpreter and translator service Professional interpreters should be available at all times and at no cost to the patient, and ideally available in any place. Despite a successful six month trial in the Top End of the Northern Territory in 1997, political lobbying and recommendations in many reports since the seventies (Brennan, 1979; Carroll, 1995; Lester, 1972; Lo Bianco, 1986; Nelson, 1978; O'Connor, 1994; RCIADIC, 1991; Territory Health Services, 1996; Watson, 1987), an Aboriginal languages interpreter service still has not been established to cater for health or any other contexts. According to Gentile et al (1996, p 16), the failure of services to use interpreters is because: At the heart of the matter is the constant identification of the need for interpreting with the status of the minority : They can't be understood; They don't speak our language; How can we deal with them in the least time-consuming way. A change in perspective can only come when it is recognised that interpreting is not done for the minority group but is necessary for the successful performance of any institution that deals with clients, or any professional with clients who do not share their language. It is as important for institutions of the mainstream as for the minority member. Cooke (1991, p 21), referring to the court context, says that miscommunication is inevitable if there is minimal or no assistance from an interpreter for Aboriginal people without fluency and proficiency in English, but that the real problem is when this goes unrecognised or is misconstrued. 6.2 Discouragement of Untrained Interpreter Use Health professionals must be discouraged from using untrained interpreters or family members as untrained interpreters are unlikely to have a suitable knowledge of lay and professional terminology or appropriate interpreting procedures which often results in inaaccurate translation (Pauwels,1995, pp 156-157) and can lead to serious miscommunication or worse: children being used as interpreters in some crucial settings is clearly inappropriate, cruel and even dangerous. It is only slowly being recognised that the use of such 'helpers' represents a serious breach of ethics on the part of the professional, official or worker from any institution that has to deal with speakers of a minority language. (Gentile et al, 1996 p 14). National Health Strategies Issues Paper, no. 6, 1993: inadequate interpreter services have led to family members, children and domestic staff doing their best to interpret and this has resulted in documented cases of miscarriages of justice, fatal and near-fatal medical consequences, denial of rights and undue suffering. (Gentile, 1991) Barker (1991) also states that the use of untrained interpreters contravenes the professional ethics of interpreting and impairs confidentiality and impartiality. In small language communities, trained interpreters will inevitably be related to some of their clients and this occurred in the interactions studied in this project. This situation obviously requires sensitive management. 31 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. 6.3 Training Interpreters need to have further training to deal with some of the issues identified in these interactions, including using correct interpreting procedures, and developing ways of interpreting medical information. Similarly, health professionals must be trained in using interpreters. Cultural awareness training for non-Aboriginal people has been advocated by many (Campbell, 1995; Jones, 1996; Mobbs, 1986; RCIADIC, 1991; Shannon, 1994; Territory Health Services, 1996; Watson, 1987) and is mandatory for most Northern Territory Government employees. Outcomes of training should be health professionals who show respect for clients and their conventions and culture (Eckermann et al, 1992, p 139 - 144; Steffensen & Colker, 1982), who recognise that Aboriginal customs are not universal different communities have different rules (Eckermann et al, 1992, pp140, 150), who recognise conflict between belief systems and world views (Eckermann et al, 1992, pp 152-153), who address the patient's model of illness by 'relating Western beliefs to Aboriginal schemata .... because there will be a framework into which the information being presented can be integrated' (Steffensen & Colker, 1982), who establish good relationships (Eckerman et al, 1992, pp 139-144; Shannon, 1994), take greater time for consultations (Mobbs, 1986), and can modify questioning techniques (Mobbs, 1986) to 'conversational modes' (Putsch, 1985, p 3347) or narratives (Cooke, 1991). 6.4 Recruitment of Staff Suggested methods of improving communication between clients and service providers also includes employment of more Aboriginal Health Workers or cultural brokers/negotiators/co-workers (Lester, 1972; Soong, 1983; Steffensen & Colker, 1982); more skilled and experienced Aboriginal staff in key contact areas (Jones, 1996; Priestley, 1995; RCIADIC, 1991; Watson, 1987); and employment of more female obstetricians and gynaecologists (Watson, 1987). 6.5 Recognition of Degrees of English Language Competence and Differences between Englishes English competence tends to be overestimated by hospital staff (Watson, 1987) and in court (Cooke, 1998). This needs to be addressed so that every client needing an interpreter is detected. There also needs to be recognition of language differences between standard English and Aboriginal English, including differences in communication styles and extralinguistic features, for example, silence, ways of exchanging information, and nonverbal communication (Eckermann et al, 1992, pp 137-139; Shannon, 1994). Lower levels of literacy also need to be recognised and catered for, with consent forms translated into Aboriginal languages (Watson, 1987), preparation and use of written educational material in Aboriginal languages and simple English (Watson, 1987), and use of video and other modes to present information (Cooke, 1998) 6.6 Further Research 32 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. An extension of this project could include a 'control' interaction between non-Aboriginal native English speaking clients and staff, to see how much miscommunication occurs in a health care interaction which is not cross-cultural. Generalisation would be improved if future projects included other types of health professionals, or focused on one group but with larger numbers, and included more Aboriginal people from a range of communities and language backgrounds. ACKNOWLEDGEMENTS: I wish to thank the following people & agencies who assisted with this project. Speech Pathology Association of Australia for partial funding. The participants involved in the data collection. Noni Bourke and Dr Anne Lowell for assistance with data collection, analysis and preparation of the manuscript. Yolngu co-workers and Dr Michael Cooke for analysis. Jenny Cush for assistance with preparation of the manuscript. REFERENCES AASH (1995). 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Ethnic Communities Council of Queensland, Brisbane. Territory Health Services (1996) Northern Territory Aboriginal Health Policy 1996, Darwin. Treichler, P.A. , Frankel, R. M., Kramarae, C., Zoppi, K. & Beckman, H.B. (1984). Problems and problems: Power relationships in a medical encounter. In C. Kramarae, M. Schultz, and W. M. O’ Barr (eds), Language and power. Pp 62-88, Sage, Beverley-Hills. Walsh, M. (1997). Cross cultural communication problems in Aboriginal Australia. North Australia Research Unit, Australian National University, Darwin. Watson, M. L. (1987). The communication problems of Tribal Aboriginal women in the maternity ward. Unpublished graduate diploma dissertation, Darwin Institute of Technology, Darwin. Weaver, A. & Weatherley, C. (1997). Looking for an interpreter or translator? Where to begin. Australian Communication Quarterly, Summer, 1996/1997. Weeramanthi, T. (1996). Knowledge, language and mortality: Communicating health information in Aboriginal communities in the Northern Territory. Australian Journal of Primary Health, 2, 2, 3-11. West , C. & Frankel, R.M. (1991). Miscommunication in medicine. In N. Coupland, H. Giles & J. M. Wiemann (eds), ‘Miscommunication’ and problematic talk. Pp 166-195, Sage, London. 37 ‘Just scratching the surface’: Miscommunication in Aboriginal health care. APPENDIX D SPEECH PATHOLOGY AUSTRALIA - NORTHERN TERRITORY BRANCH COMMUNICATION PROJECT QUESTIONNAIRE FOR HEALTH STAFF 1. Did communication problems occur during the interview(s)? never rarely sometimes often continually If so, please describe these problems: 2. How could you tell if a communication problem had occurred? 3. What do you think caused these problems? 4. a)What helped you communicate with the client / patient? b) What hindered your communication with the client / patient? 5. Did you use any strategies to prevent or repair communication problems? If so, please describe: 6. Did you notice any differences in communication when an interpreter was used? If so, please describe: 7. Were these interviews similar to real interviews that you have had with Aboriginal clients / patients? How did they differ? 8. 9. 10. a) In the past, how often have you used - Aboriginal interpreters ? - any interpreters ? b) Would you use Aboriginal interpreters again if they were available? Have you completed - Aboriginal cross cultural training? - general cross cultural training? How long have you been working with Aboriginal clients / patients? 38