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Intercultural communication in healthcare settings 247

5. Health professional–patient communication in linguistically
and culturally diverse societies

In the clinical literature, cultural diversity tends to be treated in two different
ways: either in terms of cultural awareness, drawing on the health beliefs litera-
ture described above or in terms of the “language barrier”. Language and culture
tend to be treated separately, rather than being “wired in together” (Agar 1994).
While some research plays down language problems, most of the studies ac-
knowledge them (Ahmad, Kernohan and Baker 1989; Ali 2003). And of these
latter, nearly all are concerned with issues of interpreting; the majority with pol-
icy issues (Jacobs, Lauderdale, Meltzer, Shorey, Levinson and Thisted 2001)
but others with the nature of mediated consultations and some of the drawbacks
of them.

5.1. Interpreter-mediated consultations
The linguistic and sociolinguistic studies on interpreter mediated encounters in
healthcare settings argue that the interpreter is not a neutral tool (Putsch 1985)
or a “walking bilingual dictionary” (Ebden, Carey, Bhatt and Harrison 1988) but
a linguistic and social intermediary, dealing with discourse and social interac-
tion and not just a narrow definition of language:

“Interpreters do not merely convey messages they shape, and in some very real
sense, create those messages in the name of those for whom they speak.” (Davidson
2000: 382).

Davidson’s work also clearly shows that as well as managing the conversational
flow of the consultation, interpreters also act as gatekeepers, often editing and
even deleting utterances of the patients for whom they are interpreting. To this
extent, they are certainly not acting as advocates or ambassadors. Nor are they
neutral since they act as social agents within the jointly constructed discourse
(Bührig 2001). It is not surprising, therefore, that interpreter-mediated consul-
tations are often less patient-centred than non-mediated ones (Rivadeneyra, El-
derkin-Thompson, Silver and Waitzkin 2000).
In most medical settings, more informal interpreters are used than profes-
sional ones, including staff in the hospital or clinic and family and friends of the
patients (Meyer 2001; Bührig and Meyer 2005). Yet there is a dearth of litera-
ture in this area. One area where there are some studies is in the use of children
as informal interpreters for their family. This research has focused on the views
of healthcare professionals and has identified several problems including limited
language skills and the difficulties of interpreting complicated and sensitive
subjects (Cohen, Moran-Ellis and Smaje 1999). The term “language brokering”
is used, derived from the notion of cultural brokering (Kaufert and Koolage