‘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
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‘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,
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‘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
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‘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.
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‘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
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‘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
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‘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
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‘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,
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‘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
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‘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
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‘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'
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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.
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‘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