Existence of language barriers
The existence of language barriers in the public hospitals in Addis Ababa has been stated both by the patients and healthcare providers. The healthcare providers stated that majority of the patients who have a barrier to communicate in Amharic speak Afaan Oromoo as their mother tongue. A physician at H1 (KII 4, Afaan Oromoo-speaking) estimated that more than 50% of the patients receiving medical care at the hospital are Afaan Oromoo speakers. Many of these patients come from the nearby places in Oromia region through referral system and most of them speak only Afaan Oromoo. They face problems emanating from language barriers all along the way starting from the entrance gate of the hospitals, and the healthcare providers explained that the issue of language barriers has been limiting the ability to take good quality patient history.
Interviews made with the patients and their attendants also show the existence of language barriers. For instance, IDI 8 (a woman) stated:
I cannot speak Amharic. I cannot understand what the physicians ask me, or I cannot tell them the health problem of my child. My interaction with the physician is moderated by the patients or other attendants who can speak both Afaan Oromoo and Amharic.
Similarly, IDI 12 (a man) stated:
When I go to pharmacy, I cannot communicate with the pharmacists. I have to wait until somebody who speaks both Afaan Oromoo and Amharic comes…Can a human and a tree communicate? It is like that. I cannot understand them; they cannot understand me.
Key informants stated that about 80% of the health assessment they make depends on the explanation the patients make about their health problems. If there is a language barrier, more reliance on lab tests has been reported to diagnose patients although that allows to know about the patient only 20%.
In all the hospitals where the interviews were conducted, ad hoc interpreters were used to ease language barriers. Ad hoc interpreters are searched from the patients, attendants, passing by people or healthcare providers who can speak both Amharic and Afaan Oromoo. It is stated that if these ad hoc interpreters are not available, the healthcare providers face huge obstruction in properly diagnosing and treating patients. The healthcare providers stated their worry in that the ad hoc interpreters may not ask questions the way the physician is asking, and they may also not explain the feeling of the patients adequately. There are many times when the healthcare providers or the patients are not able to find even the ad hoc interpreters. In such circumstance, a body language is used for making communication between the patients having language barriers and the physician. The case of a patient, IDI 18 (a man), is presented as follows,
I do have experiences of getting back to my home without getting the treatment I needed because of language barriers and due to not getting an ad hoc interpreter. To overcome language barriers, I sometimes rely on body language. Because I didn’t learn sign language and the physicians also have that problem, proper communication cannot take place this way. Our fathers say yoo dhukkuba ofii himatan qoricha argatu [it is only when you tell your disease that you get cure].
Patients or their attendants also described that they try their level best to explain what they feel and what they want to communicate using their very limited knowledge of Amharic.
The impacts of language barriers on the provision of health services
It was found that language barriers result in many problems for both the patients and healthcare providers. These problems are presented below under the themes: preventable medical errors, adherence to treatment and health seeking behavior, additional cost to the patients, increased length of hospital stays, weak patient-provider therapeutic relationship, social desirability bias, ethical dilemma, patients are ashamed and feel less confident, dissatisfaction and anxiety, and added burden on the healthcare providers.
Preventable medical errors
Regarding preventable medical errors, the following quote from KII 5 (physician, Amharic-speaking) indicates the case of a girl who underwent a surgery:
…The case was life threatening. I had a patient who underwent a surgery to remove an anomaly on her lung. We then performed chest tube for her. To remove the chest tube, we gave them an appointment with the help of ad hoc interpreter, and they went home. We believed that they have understood everything we told them. But they came back after 3 months, long time after their appointment date with a very critical condition, and a surgery was performed for the second time. We were blamed for not properly informing the patient about the follow up. Had we professional interpreter, problems of this kind could not happen.
KII 1 (physician, Afaan Oromoo-speaking) was also asked the question of whether he has observed patients with language barriers and whether medication problem has happened because of that. His response worth lengthy quote and it is presented as follows:
You are asking me something like spooning only once from an ocean. On any given day, I just give support for many patients having this problem. I am sympathetic about all of them. So, it is so difficult to separate only the case of one patient and present it as an example.
KII 1 (physician, Afaan Oromoo-speaking) continued,
...But simply let me tell you one very recent case; 1 month ago, at _____hospital [the name of the hospital is removed]. She had esophageal cancer. She came from Borana [a place in Oromia], she cannot speak Amharic. Esophagectomy was performed for her, and she told me that she had complication some days after the surgery. When asked about the time complication started, she told me it had been 3 days. That complication should have been treated as soon as she felt it. She told me that she had reported the complication to the physician with the help of an ad hoc interpreter. But the interpreter didn’t properly interpret and didn’t make the physician understand what happened.
The key informants explained that language barriers affect diagnosis and history taking. This, in turn, may lead to wrong diagnosis and ineffective treatment.
Impact on adherence to treatment, appointment for follow up and health seeking behavior
Key informants replied that many patients with the language barrier come back after some time with their health condition not becoming better. When asked why they didn’t take the prescribed drug, their response is usually that they didn’t properly hear what was said.
KII 6 (physician, Amharic-speaking) stated the impact language barriers have on adherence to treatment as follows:
You see the existence of this problem mostly at the outpatient department when patients come for follow-up treatment. How the patient has been taking drugs could be completely different from how it was prescribed by the physician. This could be especially related to the amount prescribed and the sequence with food that the drug is prescribed to be taken. The patient may report that he had been ordered by the physician to take the drug after 30 minutes while the correct prescription from the physician may say 30 minutes before having food. These problems happen regularly.
The possible complications and side effects of treatments may not be properly explained to the patient because of language barriers. Regarding the interviews with the patients, some patients responded that they hardly understand the date of appointment for follow up because of the language barriers. They also stated that they face problems frequently in understanding prescriptions about the number of times in a day in which a drug is taken and the precautions to be taken, for instance, concerning food and side effects. In this regard, IDI 13 (a man) explained his experience as follows:
The physician and the pharmacist told me the frequency and number of pills to be taken in a day in Amharic, but I didn’t understand. I made a guess and started taking one pill at a time, three times a day. Because I couldn’t see any good progress with my health condition, I went to a local health facility [outside of Addis Ababa, in Oromia region]. The healthcare providers told me that the way I was taking the drugs was wrong and it was supposed to be two pills at a time, three time a day. Recovery from the illness took longer time as a result.
Language barriers have also been stated by the patients as a factor that leads to the discontinuation of treatment. Patients and attendants stated that they have faced challenges in understating the prescription about how many drugs to take in a day, at what time and foods that must be taken or not to be taken. The patients stated that problems they face due to language barriers discourage them to seek healthcare when they need it. IDI 10 (a woman) narrated her deep frustration as follows,
I have previously faced several terrible incidents related with language barriers. I am still facing the same problem. I am deciding that I will never come back. My health problem could be highly contagious or whatsoever, but I prefer dying in my bed than coming back here. Due to the problem of language barriers and the associated maltreatment I faced, there were times I even thought of holding electric wire to commit suicide.
Additional cost to the patients
This study identified that high cost of treatment is associated with language barriers. If patients cannot explain their situation, the physicians involved in this study admitted that they may order a long list of laboratory tests believing that they could find by the lab tests the problems the patients couldn’t explain because of language barriers. This is reported to result in unnecessarily high cost for the patients. Both the healthcare providers and the patients replied that there are many times when treatment is delayed, and the patients are exposed for additional costs as a result. Patients also reported that they sometimes seek treatment at private hospitals where they know there are healthcare providers who speak their language although the private facilities cost them more than the public hospitals.
Increased length of hospital stays
Patients who have language barriers stay longer in the hospital than others because of language barriers. The patient with a language barrier could find it difficult to know what facility is located where, because of which they usually spend more time in the hospitals.
IDI 14 (a man) responded:
Premise of the hospital is very wide, and I don’t know where to go because posts are not written in my language.
KII 4 (physician, Afaan Oromoo-speaking) explained that patient history taking is very important to understand their health problem. If that fails because of language barriers, the patient may stay in the hospital for a longer time without receiving proper treatment. Similarly, KII 5 (physician, Amharic-speaking) said:
When told to take laboratory test order to a laboratory room, they sit keeping it. That delays treatment.
The following verbatim from a patient, IDI 15 (a man), can also indicate how language barrier can extend hospital stay or how it can delay treatment.
When I need language interpretation service, I ask for passing by people or people waiting to receive treatment if they can speak Afaan Oromoo. If there is none, I have to wait for until one comes. There are times when I wait for hours. Even when I get somebody who is bilingual, he may say he is in hurry or not interested in interpreting. Not only me. Many patients are having this problem. If I fail to get any, I have to wait until those queued up are away and those serving are free. I can then try to make them understand what I need using all means of communication because they have free time.
Interview with patient IDI 23 (a woman) also affirms the impact of language barriers on hospital stay:
Failure to understand the said procedure exposes to unnecessary delay. I sometimes spend hours wandering here and there without knowing and understanding what is said, where to go and the like. Because of language barriers there are procedures that would take four to 5 days but that could have been finished within a day had a language barrier was not there.
Weak patient-provider therapeutic relationship
When a patient cannot explain his/her problem because of language barrier, and ad hoc interpreter is used, the direct connection between the patient and the physician could be loosened, and this may put pressure on the physician to ignore the patient. According to KII 7 (physician, Amharic-speaking),
A physician should have a friendly relationship with the patient to take best quality patient history. If both the patient and the physician cannot speak the same language or if effective communication is not made due to language barriers, this friendly relation could be affected, and best quality patient history could not be generated.
On the side of the patients, IDI 23 (a woman) stated.
When I face a language barrier, I suspect what the physician is going to do on me. I believe two individuals who can’t communicate don’t feel sympathetic about each other.
Social desirability bias
According to the key informants, there could be a disease or health condition which a patient doesn’t want to be known to their family members, for instance, sexually transmitted infections. In this case, the patient may intentionally hide his/her disease and history when a family member is assigned as an ad hoc interpreter. When a family member is assigned as an ad hoc interpreter also, he/she may not properly tell the patient when the medical condition the physician told him/her is very serious; for instance, end stage cancer. Healthcare providers also stated that the interpreter may oversimplify the health situation of the patient, and this may make the patient to neglect the precautions ordered by the physician.
Language barriers have serious implications for the healthcare ethics. When ad hoc interpreters are used, for instance, there is a high probability of violating the patient’s privacy. According to KII 2 (physician, Amharic-speaking),
As a physician, we have the duty to protect the privacy of patients. As per the principle, we cannot even discuss the condition of a patient with the family members without his/her permission. But language barriers force us to violate this ethical principle when a family member is used as an interpreter. This is awful.
KII 6 (physician, Amharic-speaking) stated that ad hoc interpreters may translate communications to other languages in the way they understood, but which could be wrong. She asked,
How can I know whether that person is properly translating what I or the patient is saying?
Concerning medico-legal issue, KII 2 (physician, Amharic-speaking) stated:
If medical malpractice happens because of language barriers, how can I be responsible for that? I may have given the patient proper treatment. But if the translator tells wrongly to the patient, how can I be blamed? The ad hoc interpreter is just causal, and he could not be very serious about what I am communicating to the patient.
Patients are ashamed and feel less confident
According to the healthcare providers, when the patients fail to properly communicate about their health needs, and when at the same time, they are aware that other patients are smoothly communicating, they shift the blame on themselves; they consider themselves as weak. It is because of this perceived self-limitation that makes the patients feel ashamed and develop anxiety to communicate with healthcare providers. Patients participated in the study reported that they feel anxious when seeking treatment from hospitals in Addis Ababa due to language barriers.
KII 4 (physician, Afaan Oromoo-speaking) explained how a language barrier is exposing patients to the feeling of embarrassment and low self-image in the following way:
As we are speaking now, there is a mother in this ward who admitted her son for treatment, accompanied by her nephew. Her son was seriously ill when admitted but the mother and her nephew were very shy even to speak to anybody or to ask for help as they had a language barrier. They speak only Afaan Oromoo. Later, they brought somebody who could interpret language for them and received treatment for the child.
The healthcare providers explained the strong power such feelings could have in discouraging the healthcare seeking behavior of patients. Feeling less confident because of language barrier has the power to desist patients from expressing their pains and needs, even in emergency. IDI 2 (a woman), for instance said:
I was in labour but could not get registration card as soon as possible because I could not explain to the officers what I was feeling. Though seriously painful, I sat quietly because I feared they couldn’t understand my language.
Dissatisfaction, anger and anxiety
Key informants explained that language barriers affect patient satisfaction. Interviews with the patients also show that they have been angered and felt desperate. The case of IDI 5 (a man) is presented as follows:
I am sitting here annoyed. The doctor asked me to bring my blood test result. The lab room workers took my card and ordered me to call the doctor who ordered the lab test, I think. I went back to the doctor, and the doctor asked me to give him my card which was already taken from me by those in the lab room. But I am observing those who speak Amharic have taken back their card from the lab room. I am in this deal for four hours. I am feeling desperate.
While explaining her similar experience in the hospital, another patient (IDI 16, a woman) said:
From their face [the physician] I understand that they have anxiety in speaking to patients who have language barriers. The same is true on the side of the patients. Patients having language barriers develop anxiety to speak to the physician. Sometimes, I see physician speaking loudly to me and I feel that they could be scolding.
While explaining dissatisfaction with the healthcare due to language barriers, a patient (IDI 23, a woman) stated that such negative experience has the capacity to discourage health seeking behavior as follows:
With my previous experiences of treatment in the hospitals in Addis Ababa, if I say I was satisfied, that is quite far from the truth. Because I didn’t find physicians who are able to understand what I talk to them, I don’t feel I have got adequate health service. I could get satisfying treatment if the government had assigned language interpreters. Otherwise, I prefer not coming back to these hospitals to receive the same healthcare that I was not satisfied with. I prefer dying in my bed at home than coming back.
The patients directed their dissatisfaction and anger not only at the healthcare facilities and healthcare providers. Some patients blamed the government for failing to provide healthcare in the language they understand. IDI 24 (a man) replied:
When you do not get services in your language in your own country where you also pay taxes, you feel very bad. This reduces your trust in your government and your bond to your country. That is because you don’t see practically the concept of equality you have been told in the constitution. This is not politics. I am talking facts.
Added burden on healthcare providers
As stated above, one group of people who serve as ad hoc interpreters are healthcare providers. The key informants indicated that this voluntary service adds burden on them. Afaan Oromoo-speaking healthcare providers could be called while they are on other duties to provide language interpretation service when language barriers happen although there is no official recognition for such services. KII 8 (physician, Afaan Oromoo-speaking) elucidated the magnitude of the burden added on him because of language barriers as follows:
There are times when the Afaan Oromoo speaking healthcare providers are always called up to give language interpretation service for the patients who are not able to speak Amharic. There are times when this service appears our regular job because many patients who speak only Afaan Oromoo come here in large number. Many of our co-workers cannot speak Afaan Oromoo. Because of the friendship we have, those physicians seek interpretation assistance from Afaan Oromoo-speaking friends; to the extent of making a phone call and asking for interpretation support when we are away.
When asked whether any attempt was made to solve problems related with language barrier, KII 2 (physician, Amharic-speaking) stated:
Problems like this one are considered luxury as compared to the many other problems our hospital has. It is because of this interview that I even became conscious about the problem. Of course, I know that this is a part of human right. But we didn’t ever discuss it as a problem.
Another key informant, KII 9 (physician, Afaan Oromoo-speaking), stated that lodging official request to solve such problems needs knowing the bureaucratic procedure. As health professional, he responded:
We have rare contact with the government officials. We have frequent and direct encounter with the patients having language barriers, but we have been unable to present the existence of these problems and the need for solution to the concerned authorities.
KII 4 (physician, Afaan Oromoo-speaking) also explained his feeling about intervention as follows:
No intervention has been made. I didn’t also see while it was officially discussed. During the last 2 years, extensive catchment area has been added to this hospital from Oromia. But along with that, no consideration was given to the issue of language.
Beliefs of patients about right to healthcare in one’s own language
Some patients consider their language barrier as a burden to the healthcare providers, and they consider it as a favor made to them when ad hoc interpreter is availed. On the other hand, many patients and their attendants indicated that most of them have the conviction that it is their right to access healthcare in their own language. A patient, IDI 15 (a man) stated,
It is very clear that everybody has the right to get healthcare in his own language. I believe that it is not my duty to learn the official language. It is the responsibility of the hospitals to provide service in the language that I understand. I pay for their service. Part of the oath that the physicians make is to serve all seeking treatment with equality, and it is their duty to keep that responsibility. As far as it is said nations and nationalities have the right to be served in their language, it is the duty of the government to provide the needed services in all the languages.