Original Article

Migrants perceptions of using interpreters in health care

inr_738 461..469

E. Hadziabdic1 SRN, BSc, MScN, K. Heikkil2 MA, PhD, B. Albin2 SRNT, MScN, PhD & K. Hjelm3 SRNT, MScN, PhD
1 Doctoral Student, 2 Senior Lecturer, 3 Professor, School of Health Science and Social Work, Vxj University, Sweden

HADZIABDIC E., HEIKKIL K., ALBIN B. & HJELM K. Migrants perceptions of using interpreters in health care. International Nursing Review 56, 461469 Background: The number of foreign-born people who do not share a common language has increased due to extensive international migration, which will increase in the future. There is limited knowledge about the users perceptions of interpreters in health care. Aim: To describe how individuals from former Yugoslavia, living in Sweden, perceived the use of interpreters in Swedish healthcare services. Method: A phenomenographic approach was employed. Data were collected by semi-structured interviews during 20062007 with 17 people, aged 2975 years, from former Yugoslavia, living in Sweden. Findings: Three descriptive categories were identied: (1) prerequisites for good interpretation situations; (2) the interpretation situation aspects of satisfaction or dissatisfaction; and (3) measures to facilitate and improve the interpreter situation. The interpreters competence, attitude, appearance and an appropriate environment are important prerequisites for interpretation. The interpreter was perceived as being a communication aid and a guide in the healthcare system in terms of information and practical issues, but also as a hindrance. A desirable professional interpreter was perceived as highly skilled in medical terminology and language, working in face-to-face interaction. Conclusion: Using an interpreter was perceived as a hindrance, though also needed in communication with healthcare staff and as a guide in the healthcare system. Face-to-face interaction was preferred, with the interpreter as an aid to communication. As part of individual care planning it is important to use interpreters according to the patients desires. Healthcare organizations and guidelines for interpreters need to be developed in order for patients to have easy access to highly skilled professional interpreters. Keywords: Healthcare Service, Interpreters, Interviews, Migrants, Phenomenography, Sweden, Users Perceptions

Introduction
The number of foreign-born people has increased due to extensive global migration and this number is expected to increase in the future (International Organisation for Migration 2008). Foreign-born people often suffer from poorer health than native-born people, leading to an increased need for healthcare
Correspondence address: Emina Hadziabdic, School of Health Science and Social Work, Vxj University, SE-351 95 Vxj, Sweden; Tel: +46 470 70 80 37; Fax: +46 470 363 10; E-mail: emina.hadziabdic@vxu.se.

services (Albin 2006; Socialstyrelsen 2005). The quality of health care depends largely on good patientprovider communication (Bischoff 2003). With the exception of two previous studies, mainly concerning Asian migrants (Edwards et al. 2005; Rhodes & Nocon 2003), we have found no investigations focusing on how foreign-born people perceive the use of interpreters in contact with healthcare services. The users perspective is important to improve interpreter services, to promote communication for people with a foreign background in order to prevent the negative effects of language barriers on their health.

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Literature review

Language is central to communication (Giger & Davidhizar 2004). Communication and culture are closely intertwined. Culture inuences how feelings are expressed and what verbal and non-verbal expressions are appropriate. Factors such as physical health, emotional well-being, the context being discussed and the meaning it has may affect communication. Knowledge of the matter being discussed, skill in communication, attitudes towards the other person and towards the subject being discussed are equally important in communication. Bischoff (2003) showed that people speaking minority languages and patients who do not share the language of the health professionals are at a double risk of receiving less than optimum care because they are more exposed to health risks, with an additional risk posed by language barriers. Language barriers in health care for non-English-speaking patients have led to poorquality care (Rhodes & Nocon 2003), fewer medical contacts (Bernstein et al. 2002) and higher costs (Hampers & McNulty 2002). Bischoff et al. (2003) found that crucial stages in the nursing process, such as assessment of individual needs and planning of measures, could not be carried out properly, subsequent treatments were hampered, symptoms were underreported and much fewer referrals were made. One important way to improve the quality of care is by the improvement of communication between healthcare professionals and foreign-born people using professional interpreters (Bischoff et al. 2003; Jacobs et al. 2001; Rhodes & Nocon 2003). Use of trained interpreters has resulted in increased clinic utilization, and a decrease in repeated visits without any simultaneous increase in cost (Bernstein et al. 2002). Previous studies mainly of Asian migrants in the UK (Edwards et al. 2005; Rhodes & Nocon 2003) identied that the qualities of a good interpreter include interpreters language prociency in both their own mother tongue and in English, as well as the interpreters character and attitude (Edwards et al. 2005). Thus, there is limited knowledge of how foreign-born people perceive and experience the use of interpreters in healthcare service.
Use of interpreters in Swedish healthcare service

private enterprises outside health care. These employed professional interpreters are either specially trained or not. The law does not dene who can be used as an interpreter. Family members or friends and bilingual healthcare professionals are frequently used as interpreters (Brooks et al. 2000; Gerrish et al. 2004; Kuo et al. 2007; Rhodes & Nocon 2003; Rivadeneyra et al. 2000) due to lower cost and easy access (Gerrish 2001; Gerrish et al. 2004).

The study
Aim

The aim of this study was to describe how individuals from former Yugoslavia, living in Sweden, perceived the use of interpreters in Swedish healthcare services. In this study, the concept of interpreter includes both professional and informal interpreters (family members, friends, bilingual healthcare professionals).

Method
Design

A descriptive and explorative study with a phenomenographic approach was used. Phenomenography aims to understand, analyse and describe the individuals perceptions of different phenomena (Marton & Booth 1997). Perception is central in phenomenography and based on qualitative variations in peoples perceptions of the surrounding world, such as how they think, conceptualize, perceive, understand and remember various aspects of a phenomenon.
Participants

Swedish law states that people who do not understand or speak Swedish have the right to access to an interpreter in all encounters with public institutions, such as healthcare services (Frvaltningslagen 1986: 223). Interpreters guidelines state that professional interpreters should literally translate, be neutral, ensure condentiality and not make any other statements unrelated to the situation (Kammarkollegiet 2004). Responsibility for calling upon an interpreter lies with the institutions healthcare professionals (Kammarkollegiet 2004). Interpreter service ofces are often run by the municipality or as

A purposeful sampling procedure was used and included individuals who had Serbo-Croat (Bosnian/Croatian/Serbian) as their native language, and had used interpreters on several occasions during the last 6 months in different healthcare services in Sweden. Serbo-Croat-speaking persons from former Yugoslavia were chosen because they constitute the second largest group of migrants living in Sweden (Sveriges Ofciella Statistisk, SCB 2007). Representatives of adult education facilities for immigrants and immigrants associations for former Yugoslavians were contacted to invite people of different gender, age, educational level and length of residence in Sweden to participate. Verbal and written information about the study was given in Serbo-Croat by the rst author. The study included ten women and seven men, aged 2974 years (median 55 years; see Table S1). All have valid residence

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permits. Their educational levels and length of residence in Sweden (median 10 years, range 4 to 13) are described in Table S1.
Data collection

Data were collected between January 2006 and February 2007. Semi-structured interviews were used, which is the preferred method of data collection in phenomenography (Marton & Booth 1997). An interview guide was developed based on literature and peer-reviewed by a researcher experienced in trans-cultural communication. The interview guide focused on perceptions of using interpreters in health care, problems and improvements relating to the use of interpreters. Examples of question are: How do you perceive use of interpreters? Please describe a positive and a negative situation where you have used an interpreter. Two pilot interviews were conducted, which led to minor corrections of language and order of questions, but they were included in the study. In accordance with participants wishes, 16 of the interviews took place in their homes and one in an ofce. Each interview took about 1 h. The interviews were carried out in Serbo-Croat by the rst author, who is bilingual. All interviews were translated into Swedish by the rst author, and the translation was checked by a professional translator (Papadopoulos & Lees 2002).
Ethical considerations

Phenomenographic research relates to the core question of credibility, the relationship between the empirical data and the categories for describing ways of experiencing a certain phenomenon (Sjstrm & Dahlgren 2002). The study ensured credibility by means of quotations, which support the relevance of the categories. The rst author identied the categories communicated by conducting, transcribing and translating interviews and analysing the data. Co-authors double-checked the content of the categories to conrm the relevance. The authors have different research experience but all have researched in the area of migrants health. The credibility of the study is further ensured by the way differences and similarities between the respondents are supported by the data. Giving a precise description of each part of the research process makes it possible to replicate the study (Sjstrm & Dahlgren 2002). According to phenomenography there are a limited number of ways experiencing a phenomenon, and by including participants with different backgrounds, the variations within a group are likely to be covered (Marton & Booth 1997).

Findings
The descriptive categories that emerged from data are described in Fig. 1. The categories are horizontally related and no hierarchical relation was found. In general, the participants preferred to speak through a professional interpreter but expressed dissatisfaction with some aspects of this encounter.

Written informed consent was obtained from the participants (Declaration of Helsinki 1996). To preserve the condentiality of the participants data, the audiotapes and transcripts were anonymized and coded by number. The analysis and presentation of the data were done in a way that concealed the participants identity. All the collected data were stored in a locked space which can only be accessed by the principal investigator.
Data analysis

Prerequisites for a good interpretation situation

Data were analysed using the principles of phenomenography (Sjstrm & Dahlgren 2002). The procedure consisted of seven steps. Familiarization: reading through the transcripts to become familiar with the data and correcting any errors in transcription. Compilation: identifying the most signicant statements given by each participant, and asking questions of the text. Condensation: reducing longer statements to nd the core of each answer or dialogue. Grouping/classication: bringing similar answers together. Comparison: comparing the selected statements to nd dividing lines between variations, establishing categories, which are distinct from each other and revising the preliminary analysis. Labelling: naming categories to capture the essence of the understanding. Contrasting: comparing and contrasting the categories obtained to nd the unique characteristics of each category.

The prerequisites for a good interpretation situation were met when interpretation was carried out in a secluded room and by a person of the same gender, especially during sensitive and/or physical examinations. Non-provocative and/or neutral clothes worn by the interpreter inspired respect, signalled competence and a professional attitude and ensured that nothing distracted the conversation. The participants perceived that education and knowledge of medical terminology and the interpreters experience of interpretation and translating ability were important. Understanding and trust were increased by interpreters ability to adapt to the participants use of language and that they spoke the same native dialect: . . . Its important that he is well educated. . . . but the most important thing is that he has medical knowledge so that the patient and the doctor do not disagree when it comes to treatment. . . . Its good when an interpreter speaks the native language of a patient.

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Prerequisite for good interpreter situation

The interpretation situation Aspects of

Measures to facilitate and improve the interpreter situation actively or passively solving problems of misunderstanding healthcare professionals role in facilitating the use of an interpreter. Better training for interpreters

Physical environment, the interpreters appearance, education in language and medical terminology, competence of the interpreter and the form of interpretation either face-toface or by telephone

Satisfaction with the interpretation as a result of the behaviour of the interpreter with the interpreter as a communication aid with the interpreter as a practical helper and informative guide

Dissatisfaction with the interpretation as the interpreter limits transferred information due to inadequate translating techniques, lack of trust and trust in confidentiality

Fig. 1 The outcome space. Three descriptive categories, consisting of the varying perceptions experienced by ex-Yugoslavian migrants.

He (the interpreter) should be able to make an assessment as to how good our hearing is and from which part of the country we come from and if we are going to be able to understand him. Most participants preferred personal contact with face-to-face interpretation than by telephone. Face-to-face interaction made it possible to follow the interpreters body language. However, when sensitive issues and/or physical examination were carried out, respondents preferred interpretation by telephone because they could then be more anonymous. Participants perceived that on unexpected visits, they seldom had access to a professional interpreter. Family members were then needed to act as interpreters. When visits were planned, professional interpreters were booked. If participants sensed an open attitude from the interpreter and had condence in him/ her, they felt able to speak about everything: . . . When it is a personal interpreter then it feels different. If I have pain, then I can show it and he sees me and its different when he interprets. But in certain cases when you want to be alone with the doctor, then its good to have a telephone interpreter . . . sometimes you feel ashamed, sometimes it feels unpleasant or uncomfortable to say certain things that you have experienced, then you can think that its taking place via a (telephone) line and an interpreter cannot see you, he just knows your name. . . .

The interpretation situation Aspects of satisfaction or dissatisfaction

Satisfaction with the interpretation as a result of the behaviour of the interpreter

The participants had a sense of security through the behaviour of the interpreter. They felt condent that the translation would be literal, without any value judgment being made. They were satised with the behaviour of showing respect, keeping the code of condentiality, and a professional and neutral attitude towards them. They expressed satisfaction if there was a good relation between themselves and the interpreter. Showing respect during physical examinations, particularly concerning intimate parts of the body, was also important: . . . show me respect, I am older than him (the interpreter), could be his mother, by every time the doctor is going to examine me turning his head away from me. What the doctor says, he then literally translates for me. The participants willingness to discuss all their problems openly was related to the condence in the interpreter, which was connected to the interpreters bodily language and physical appearance, including clothes. Characteristics that contributed to the development of trust in him/her were the ability to show empathy, inspire security, kind treatment, and giving a calm and secure impression:

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His own behaviour at the rst meeting with him . . . he cheerfully greets us. . . . his clothing . . . his treatment, his rst response to us. It can be noted simply. Body language, tone, intuition were among the most important things.
Satisfaction with the interpreter as a communication aid

uncertain about condentiality when speaking openly about sensitive topics in the presence of a third person: . . . when you cannot speak the language, then you dont know whether the interpreter has correctly translated what you have said. . . . . . . I dont feel secure and dont have condence in the interpreter when it comes to sensitive subjects. Using an interpreter was perceived as a disability. It created a feeling of dependency and decreased privacy in the caring relationship. There were also questions as to whether they could trust interpreters to adhere to the code of condentiality. Participants became suspicious and played a kind of waiting game as certain information was not discussed in the presence of the interpreter. They also felt that the atmosphere and relationship with healthcare staff was negatively inuenced if the interpreter was present at the consultation: I feel sad . . . when you are dependent on an interpreter then you feel handicapped. Then you feel inadequate because you cant do it yourself. You are always dependent on someones help. Its a bit like when you have a pain in your leg and you are dependent on a walking stick and its the same thing with an interpreter. It feels like a walking stick. . . . An interpreter reduces the intimacy between doctor and patient . . . a lot remains unsaid due to the presence of a third person. Participants perceived that interpretation by telephone was the most commonly used form of interpretation. They expressed dissatisfaction with this because they were unable to observe the body language of the interpreter, and technical problems such as impaired hearing because of poor sound quality of the telephone or a speakerphone being out of order limited the communication. These factors in combination with being unable to control the identity of the interpreter caused feelings of insecurity further affecting the communication: (Interpretation by telephone) . . . When I point to where I have pain, he (the interpreter) doesnt see it. He doesnt see and cannot say what I say and feel. . . . so I cant know who the other person is, but if I can see him and his facial expressions when he speaks then you can see whether or not he is interested in helping to explain, translate. . . . The participants complained about lack of continuity in the use of interpreters. If someone was perceived as a good interpreter they wanted to keep him/her, as it took a long time to develop trust with a new person. A problem expressed by the participants was when the interpreter did not turn up at the appointed time, which could cause

The use of an interpreter was benecial when people not speaking the same language could understand and make themselves understood. The participants also perceived body language to be part of the interpretation. The participants predominantly preferred a professional interpreter. Few people wanted family members or bilingual healthcare professionals as interpreters. However, most respondents could see advantages in using family members as interpreters because they also provided support, knew of their complaints, trusted them more and helped them with practical matters. Some accepted bilingual healthcare professionals as interpreters, because they were educated in health care, could assist with practical matters, had good interpretation skills and provided effective help without delay: It is most usual that she (her daughter) already knows about all my problems. It feels easier, she helps me. . . . I also get help by them driving me and that makes me feel secure. . . . and he (healthcare personnel) helped me with everything. . . . He could speak the language and that feels easier. . . . Using a professional interpreter enhanced the possibility of receiving adequate treatment. Their professional training, together with high-quality language skills, helped participants to understand and to be understood. Some participants also felt that the professional interpreter had been trained in certain interpretation methods, which improved the quality of communication.
Satisfaction with the interpreter as a practical helper and informative guide

Participants perceived that the interpreter also had an important role in helping them to nd the right way to and within the healthcare system if they were unable to read signboards. The interpreters could help with practical matters such as reading letters from the hospital and contacting healthcare staff: . . . on the way out of the examination room, the interpreter always helps me. . . . so they help me to nd the way out. They also offer help with transport home.
Dissatisfaction with the interpretation as the interpreter limits transferred information

Most participants felt insecure as to whether or not interpreters were able to literally translate what they said. They also felt

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cancellation of the consultation and a need to book a new appointment. They seldom received an explanation why the interpreter did not come. Another problem was the unwillingness of healthcare professionals to book an interpreter when they felt they could carry out the consultation without one. This resulted in limited possibilities of communication. Participants viewed an interpreter as part of the healthcare staff: . . . the interpreter was booked but nobody came . . . I didnt know what I should do because I couldnt talk . . . to the doctor. I asked for the interpreter and she said not come, so I turned around and went home. It felt unpleasant. . . . That they (the healthcare personnel) are not so willing to book an interpreter. Thats not good. . . . without an interpreter, I speak, but I dont know whether I have understood him correctly or if I have said the right thing, so that he understands me.
Dissatisfaction due to inadequate translating techniques, lack of trust and trust in condentiality

Family members also became involuntarily responsible for the interpreter role. Some people mentioned the inappropriateness of using children as interpreters because of the high risk of stress disorders affecting them if they had to translate emotionally tense matters. As parents they could not say everything to their children: It doesnt feel right for me to put the responsibility on her (the daughter). . . . There are employed interpreters and I have to make my daughter responsible. . . . even if I have a daughter who is a doctor, I cannot say everything to a doctor if she is interpreting. . . . Bilingual health professionals as interpreters were also perceived as a disadvantage because they were not trained interpreters, did not have a duty of condentiality and could make imperfect interpretations, which negatively affected understanding. There were also negative perceptions about the use of professional interpreters as in some cases the interpreter had limited translation skills, leading to lack of understanding. Participants also stated that it was more difcult to convey an emotion or feeling through an interpreter: . . . an interpreter, you can never convey your feelings or emotions in the same way that you can when you speak your own language or when you can speak Swedish.
Measures to facilitate and improve the interpreter situation
Actively or passively solving problems of misunderstanding

Participants perceived that they often had a professional interpreter who spoke the wrong language/dialect which resulted in inadequate communication. The professional interpreters religion or country of origin made some of the participants uncertain whether or not the professional interpreter translated literally: I belong to a particular nationality, and I could get an interpreter who belonged to another nationality . . . I didnt say everything then that I was suspicious that he was not going to interpret everything I said. Sometimes the interpreter was perceived to show a superior attitude and some of the participants did not trust the interpreter to maintain condentiality. In both cases, they describe their health problems in front of this person: It has happened, for example, when I have been in the company of a few friends that they have talked about me. I then asked how they knew about it. They then said that they had heard it from some of their friends and sometimes it has happened that they have also mentioned the name of an interpreter. Since then, I have been extremely careful what I say in front of an interpreter, because some of them are not able to keep quiet. . . . The participants also perceived that communication could be negatively affected when using family members because they were not trained interpreters. During physical examinations they felt ashamed when they had to show the intimate parts of their body in the presence of family members of the opposite sex.

Some participants experienced problems of not being understood during a consultation. This was solved either by asking the interpreter to repeat what he/she had said until they had understood, or by asking for another interpreter. In some cases the consultation had to be cancelled. In one case the participant could speak some Swedish and thus asked the interpreter to leave the room and instead asked the healthcare staff to speak slowly in Swedish: . . . shall try and speak Swedish and if he doesnt understand something then he shall repeat himself ve times if necessary. . . . Some participants had a passive strategy and were afraid to openly deal with the problem and continued, although their understanding was limited. They felt it difcult to reject the interpreter, as they had no opportunity to inuence their choice and booking: How could I replace him (the interpreter) when he was already there? I cannot communicate with . . . the doctor. . . . What shall I do when I cannot choose the interpreter? When I came

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to the health centre, the interpreter was already there. I cannot say that I do not want a certain interpreter. If I refuse, then there is no other interpreter there.
Healthcare professionals role in facilitating the use of an interpreter

The participants wished that healthcare professionals planned for and booked an interpreter, in order to ease access to interpreters. They preferred exibility in use of either professional interpreters or bilingual staff. They wished also that the healthcare professional would strive for consistent use of the same interpreter eliciting patients preferences. There was also a desire for information from healthcare professionals about where to turn to book an interpreter: . . . every notice to attend healthcare services you receive, it says that you have the right to an interpreter and it says that you can ring a number and book an interpreter, and that if you have particular condence in a specic person then it will be possible for this person to interpret.
Better training for interpreters

The training of interpreters, both in language skills in general and in medical terminology specically, was perceived as a way to improve interpretation. Another measure was to use bilingual healthcare staff and to develop an agency for non-Swedishspeaking people to whom they could turn for help with practical problems relating to language difculties such as booking appointments with healthcare services, reading letters about results from examinations, nding the way to different institutions, booking a taxi, etc. Employment of more bilingual healthcare professionals was regarded as an improvement: . . . every time I have an appointment with the doctor, that I have someone that I can turn to, to say that I need an interpreter and that she (the interpreter) knows that she should help me. That she will help me with transport. . . . Someone who could help us with all practical things. . . . . . . employ more personnel in healthcare who can speak my language. . . . He (healthcare personnel) always came up to me when he was working and talked to me. Without him, I didnt talk at all.

Discussion
There is limited knowledge concerning perceptions of interpreters in health care from the users perspective. The ndings in this study showed that from the users perspective, the main function of an interpreter was to be a communication aid and a guide within the healthcare system concerning information and practical issues. The wish was to have a professional interpreter, highly skilled in communication and language, in face-to-face interaction.

Our ndings concerning a professional attitude in terms of the interpreters competence, behaviour and appearance and his/her function as a guide in the healthcare system have not been discussed previously. A professional attitude is in accordance with Swedish recommendations for professional interpreters (Kammarkollegiet 2004), while the function of being a guide in the healthcare system is not addressed. Thus, the users desire is in contrast to the recommendations and differs from healthcare practice but should be met by a revision of the guidelines and a system where either interpreters or healthcare staff meets the need. In this study, the respondents wanted the services of professional interpreters. This is in contrast to results of previous studies involving mostly Asian-born respondents in the UK who preferred family members as interpreters (Edwards et al. 2005; Rhodes & Nocon 2003). In some cultures it is a tradition for the family to make decisions on behalf of patients (Giger & Davidhizar 2004). The respondents in our study were European migrants in Sweden, which might explain the difference in preferences. Also, the organization of health care and interpreter services differ. Family members without formal training in interpretation were preferred rather than having no interpreter at all. This highlights the need to develop a healthcare organization in which family members or relatives are not the only interpreter alternative. Participants in this study described the use of an interpreter as a sort of hindrance but they were dependent on interpreters in their healthcare contacts. They were more satised with face-toface contact in the interpretation situation. Only in sensitive concerns was a telephone interpreter preferred (Hornberger et al. 1996; Lee et al. 2002). This means that face-to-face interpretation should be the aim and it is the responsibility of both healthcare professionals and patients to communicate and agree on the kind of interpreter that is preferred. Interpreters trustworthiness was perceived as important for a good interpretation situation. As previously found (Edwards et al. 2005; Kaufert & Putsch 1997), this was dependent on personal character, attitude, skills in medical terminology and in the language spoken by the migrant, as well as the interpreter not being conspicuous, e.g. dressed modestly, showing respect and keeping the code of condentiality. The participants in this study represented only one group of foreign-born people living in Sweden, ex-Yugoslavians, the second largest group of migrants in Sweden (SCB 2007). The language in the studied group differs from Swedish and interpreters are often used in health care. The data gave a consistent picture although the studied population included people of different age, gender, educational level and time of residence in Sweden. Thus, a broad range of experiences are represented and

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the variations within a group of people are likely to have been covered (Marton & Booth 1997). Findings from a qualitative study do not aim to arrive at a generalized conclusion, but the results can be transferred to other settings or groups with similar characteristics (Sjstrm & Dahlgren 2002). In this study, a bilingual interviewer was used, from the same ethnic group as the respondents, thereby diminishing barriers related to communication and translation problems (Douglas 1998; Elam & Fenton 2003). This made it easier to develop an environment for discussing sensitive issues through a shared and appropriate language and a shared cultural understanding (Douglas 1998; Elam & Fenton 2003; Papadopoulos & Lees 2002). An ethnically matched interviewer might raise concerns about condentiality (Elam & Fenton 2003), but the interviewer had no relation to the respondents, either professional or private.

This study was performed with grants from the AMER research prole (Labour Market, Migration and Ethnic Relations), Vxj University, Sweden and HSF (Rdet fr hlso- och sjukvrdforskning i sdra Sverige, Council for Health and Healthcare Research), Sweden.

Author contributions
E. Hadziabdic and K. Hjelm were responsible for the study conception and design and E. Hadziabdic, K. Hjelm, B. Albin and K. Heikkil were responsible for the drafting of the manuscript. E.Hadziabdic performed the data collection and data analysis under critical revision from K. Heikkil, B. Albin and K. Hjelm. E. Hadziabdic and K. Hjelm made critical revisions to the paper. K. Hjelm, B. Albin and K. Heikkil supervised the study.

Conclusion
Having an interpreter was perceived by the users as a hindrance but necessary for communication with healthcare staff and nding their way in the system. The users perceived the interpreters role as a communication aid and desired face-to-face interaction with highly skilled professional interpreters. Interpretation should be carried out with a correct technique and in the right environment to facilitate high-quality communication based on a trustful relationship, ensuring condentiality.
Implications for nursing practice

References
Albin, B. (2006) Morbidity and Mortality among Foreign-Born Swedes. Doctoral dissertation. Department of Health Sciences, Division of Geriatrics, Lund University, Lund. Bernstein, J., et al. (2002) Trained medical interpreters in the emergency department: effects on services, subsequent charges, and follow-up. Journal of Immigrant Health, 4 (4), 171176. Bischoff, A. (2003) Caring for Migrant and Minority Patients in European Hospitals. A Review of Effective Interventions. Institute for the Sociology of Health and Medicine, Vienna. Available at: http://www.mfh-eu.net/ public/les/mfh_literature_review.pdf (accessed 20 November 2006). Bischoff, A., et al. (2003) Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral. Social Science & Medicine, 57, 503512. Brooks, N., et al. (2000) Asian patients perspective on the communication facilities provided in a large inner city hospital. Journal of Clinical Nursing, 9, 706712. Douglas, J. (1998) Developing appropriate research methodologies with black and minority ethnic communities. Part I: reections on the research process. Health Education Journal, 57, 329338. Edwards, R., Temple, B. & Alexander, C. (2005) Users experiences of interpreters: the critical role of trust. Interpreting, 7, 7795. Elam, G. & Fenton, K.A. (2003) Researching sensitive issues and ethnicity: lessons from sexual health. Ethnicity & Health, 8 (1), 1527. Frvaltningslagen (1986: 223). Administration Law. Gerrish, K. (2001) The nature and effect of communication difculties arsing from interactions between district nurses and South Asian patients and their carers. Journal of Advanced Nursing, 33 (5), 566574. Gerrish, K., Chau, R., Sobowale, A. & Birks, E. (2004) Bridging the language barrier: the use of interpreters in primary care nursing. Health and Social Care in the Community, 12 (5), 407413. Giger, J.N. & Davidhizar, R. (2004) Trans-Cultural Nursing Assessment and Intervention, 4th edn. Mosby, London. Hampers, L.C. & McNulty, J.E. (2002) Professional interpreters and bilingual physicians in a pediatric emergency department. Archives of Pediatrics & Adolescent Medicine, 156, 11081111.

Interpreters, nurses and other healthcare staff need to be trained in developing a professional attitude and methodology to improve interpretation in face-to-face communication. Nurses must become aware of the importance of avoiding the use of families/relatives and bilingual healthcare staff as interpreters; telephone interpretation should be used only after an agreement with the user. Nurses need to plan in advance for the use of interpreters in accordance with the patients wishes. This has to be a natural part of the individual care planning. It is also necessary to offer easy access to professional interpreters as part of daily work and to nd ways to guide the users in the healthcare system. Cost-effective, high-quality care can only be developed if limited and poor communication is prevented, thereby decreasing the risk of misunderstandings and delayed health care. This can best be achieved by offering and using highly skilled interpreters in situations where there is language incompatibility.

Acknowledgements
We are grateful to Dr Alan Crozier, professional translator, for reviewing the language. We also thank Professor Kate Gerrish for helpful criticism in planning the study.

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