“When you hear hoofbeats, think horses not zebras.” — Dr. Theodore Woodward
In medical school, many doctors learn about Dr. Woodward’s saying being advised, when making a diagnosis, to focus on the likeliest of possibilities instead of on the unusual ones. However, sometimes there is a need to look for zebras, or fascinomas, highly infrequent or interesting cases or diagnoses. The message is the requirement to be open (prepared) to exotic medical diagnoses when a more common diagnosis is thought. Since encounter outcomes depend, besides on providers’ expertise, on both interpreter skills and patient health literacy and interpreters work as distributors of health literacy as well as cultural mediators, interpreters have to be ready and knowledgeable.
Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to understand and use information in ways which promote and maintain good health.
(WHO, according to Nutbeam, 2008)
Health literacy can be described as a compilation of functional literacy (bare literacy) and a more advanced literacy level (conceptual) that would include both the capacity of communication and interaction as well as, in the case of individuals with even higher literacy levels, the possibility to develop a critical point of view (Povoroznyuk and Dzerovych, 2017).
Because of their life circumstances, LEP patients’ health literacy usually falls at the level of bare functionality, with only a few individuals reaching up to the conceptual communicative/interactive level. Additionally,
as age increases, so do the deficits in literacy as a result of declining cognitive function, increased time since formal education, and decreased sensory abilities. (…) Patients with inadequate health literacy often feel a sense of shame and decreased worth.
Safeer and Keenan, 2005
Among those patients, and among all LEP patients, independently of their literacy level, providers can follow some simple steps to enhance understanding (Safeer and Keenan, 2005):
- Slow down to assess patient’s health literacy skills.
- Use common language instead of medical terminology.
- Use pictures or sketches to enhance understanding and later recall.
- Limit information given, and repeat instructions.
- Use teach-back methodology.
- Be respectful, caring, and sensitive. Empower patients.
Steps to which interpreters should actively suggest sticking to during pre-sessions, or at least belatedly hint during encounters, to assure complete patient understanding. And to further enhance individuals’ autonomy within the conceptual level, interpreters may as well take advantage of paratranslation.
Paratranslation is the zone of transition and transaction of any transcultural exchange, the decisive location for the success or failure of any processes of cultural mediation. (…) Paratranslation is a nice and practical umbrella term for all the verbal and non-verbal texts constituting the ‘environment’ of a translation.
Although the following information was provided as pertaining solely to the written word I would like to extend this concept to the spoken language as well. Hence, wherever you read paratranslation, you could read likewise parainterpretation.
Paratranslation and parainterpretation are, respectively, translation and interpretation processes that incorporate culturally appropriate modifications from the original source to enhance meaning and facilitate understanding by the target audience.
In pragmatic translation, the purpose is essentially to translate a message as efficiently and as accurately as possible. The emphasis is on the content (…) ethnographic translation is not limited to placing a message within its broader cultural context; (…) in the process of transcoding one is frequently called upon to supply supposedly equivalent terms for traits that are analogous rather than identical in the two cultures.
(…) Perfect equivalence, in the sense that the messages evoke identical responses in the speakers of the two languages, is probably impossible of attainment (…). To achieve absolute equivalence in this process of transcoding presupposes an identity of cultural or socially shared experience between the two speech communities.
(…) The attitudes and values, the experience and tradition of a people, inevitably become involved in the freight of meaning carried by a language. In effect, one does not translate LANGUAGES, one translates CULTURES.
To help understand what paratranslation (and parainterpretation) really entails and how it can assist enhancing provider-patient transcultural communication, Povoroznyuk and Dzerovych (2017) deconstruct the process into several PARATRANSLATIONAL PROCEDURES: rewriting, transediting, terminological variation, localization, and transcreation:
- Rewriting – The expression of the original idea not as a translation, but as a new text to accommodate for reader’s accessibility. This can be accomplished adapting and/or manipulating the ideas of the original script by reducing (shortening) or amplifying (lengthening) them.
- Transediting – Implying both translation and edition of the original text, embraces several typologies. It may include certain cleaning up (idiomatic differences, corrections); the change in the final function of medical terms such as chemical, generic of trade names, and drugs. There are situational instances where the meaning is kept, but not the wording; words may require to be changed depending on the situation (colleague, journal, patient). And cultural typologies, arising out of current divergences among biomedical cultures (mainstream culture of medicine and others).
- Terminological variation – In a multicultural setting it may be needed, to assure understanding, to change the medical terminology (it may be culture-dependent; hence, NOT transferable); GILT (Globalization, Internationalization, Localization, and Translation).
- Localization – The adaptation of the vocabulary (such as measures, wording, and presentation of dates) to a local audience.
- Transcreation – A noun cradled to name creative translation, the sound which already hints to certain unfaithfulness to the original. For example, an original American health booklet transcreated into Spanish for the local Hispanic population may include changes in statistics, in its register, contain new information (additional or updated information not present in the original English document), and have different pictures presented.
(…) a covert translation is a translation which enjoys the status of an original text in the receiving linguaculture, and is not marked pragmatically as a translation at all. In order to meet the special needs of the new addressees, the translator must take different cultural presuppositions into account and create an equivalent speech event in the target culture. In order to achieve this, a ‘cultural filter’ will be applied. (…) Since in translation ‘meaning’ is of particular importance, it follows that translation cannot be fully understood outside a cultural frame of reference. (…)
The practice of paratranslation provides freedom to the translator but needs a very critical approach and sensibility. It should be used only in circumstances where the full comprehension of the original text by the target population would be otherwise in jeopardy.
The case of parainterpretation, although it might be extremely useful in certain circumstances provides much more trouble to exercise than that of paratranslation because it may easily get into direct conflict with the interpreter’s Standards of Practice and/or Code of ethics (NCIHC, 2005; IMIA, 2007). In Canada, where the role of the interpreter does not involve that of a cultural broker (Povoroznyuk and Dzerovych, 2017), the process would most likely be impossible to apply. Hence, the potential use of parainterpretation is something that requires further through evaluation and discussion among practicing professional healthcare interpreters prior to any standardized implementation.
- Casagrande, JB. 1954. The Ends of Translation. International Journal of American Linguistics 20(4): 335-340.
- House, J. 2016. Translation as communication across languages and cultures. Routledge – Taylor & Francis Group, London and New York.
- IMIA (International Medical Interpreters Association) 2007. Medical Interpreting Standards of Practice. 49 pp.
- NCIHC (National Council on Interpreting in Healthcare) 2005. National Standards of Practice for Interpreters in Health care. 20 pp.
- Nord, C. 2012. Paratranslation – a new paradigm or a re-invented wheel? Perspectives: Studies in Translatology 20 (4): 399-409.
- Nutbeam, D. 2008. The evolving concept of health literacy. Social Science & Medicine 67:2072-2078.
- Povoroznyuk, R.V. and Dzerovych, N.I. 2017. Zebra Hoof beats: Getting Your Message Across to the Patients. Workshop at IMIA Annual Conference, Houston, TX.
- Safeer, R.S., Keenan, J. 2005. Health Literacy: The Gap Between Physicians and Patients. American Family Physician 72(3):463-468.
- WHO, World Health Organization; http://www.who.int/en/