Transletters. International Journal of Translation and Interpreting 7(2) (2023), pp. 18-44 ISSN 2605-2954

Examining Teach-back Strategies in Healthcare

Interpreting through Case Study Research

Cristina Álvaro Aranda

Universidad de Alcalá

Received: 07/02/2023

Accepted: 01/05/2023

Abstract

Clinicians engage in interactions with migrant patients that often experience low health

literacy levels and linguistic barriers. Institutions are tasked to provide adequate

interpreting services and ensure effective communication strategies. Among these, the

teach-back (TB) method allows clinicians to check the patient’s level of understanding

by asking them to repeat what they have understood after health information is

delivered. Despite its relevance in mono-/bilingual consultations, studies on TB when

an interpreter is present are scarce. Drawing on case-study research and conversational

analysis, this paper examines a dataset of interpreted-mediated interactions involving

TB and occurring in a Spanish hospital. We aim to I) isolate instances of TB, II) detect

scenarios where TB is used, III) develop an exploratory and descriptive analysis of two

illustrative cases, and IV) provide suggestions for interpreter-clinician collaborative

usage of TB in migrant healthcare provision.

Key words

Healthcare interpreting, Teach-back, Health literacy, Cross-cultural communication,

Case-study, Conversational analysis, Interprofessional collaboration

 

Introduction

Communication in medical settings is complex. Throughout their education,

providers are taught to use jargon to describe body structures and processes,

disorders, and treatments, which may hinder patients’ understanding and even

Cristina Álvaro Aranda

jeopardise effective, safe, patient-centred care (Kimbrough, 2007; Pitt and

Hendrickson, 2020). In this context, plain language communication has gained

increasing support, as healthcare providers are responsible for educating patients

and conveying their goals and outcomes in an understandable and meaningful

way (Mendoza, 2018). The teach-back (TB) method is one of the strategies

available to medical staff to achieve this goal. It helps to assess the patients’

knowledge after health education is provided, by requesting them to state in their

own words what they have heard and understood, thus giving providers an

opportunity to check comprehension, and clarify concepts and

misunderstandings (Mahramus et al., 2014; Slater et al., 2017). This is relevant

for migrant healthcare delivery, as it is riddled with language and cultural

differences and conditioned by the effect of cultural shaping of symptoms,

diagnosis, and illness management (Rousseau and Frounfelker, 2018). In this

sense, TB has proved to be particularly useful in populations with low levels of

health literacy, including immigrants, ethnic minorities, and people who did not

speak the local language during early childhood (Caplin and Saunders, 2015;

Tamura-Lis, 2013).

Among available facilitators of communication in language-discordant medical

consultations (visual cues, hand-made writings, body language, web-based

translation applications, dictionaries, flow charts, ad hoc interpreting, etc.),

relying on professional interpreters has been described as the most effective

strategy, since they are key actors to improve health and patient safety (Kletečka-

Pulker et al., 2021). Although the usage of TB with migrant patients and/or

refugees has been documented in the literature (e.g., Juckett, 2013; Patel et al.,

2021; van der Giessen et al., 2021; Morony et al., 2017), the data are sparse on

its efficacy when interpreters are involved (see Brega et al., 2015; Drebold, 2020;

Riggs et al., 2021 for some exceptions). Drawing on case-study research (Yin,

2009), this paper resorts to conversation analysis (Pomerantz and Fehr, 2011) to

examine a selection of interpreter-mediated interactions in which TB is present

and which occurred in a hospital in Madrid, Spain. This general aim is divided

into four specific objectives: I. isolating instances of TB in a dataset of language-

discordant, interpreter-mediated medical interactions, II. proposing a taxonomy

of scenarios where TB is used, III. developing an exploratory and descriptive

analysis of two illustrative cases, and IV. providing suggestions for interpreter-

clinician collaborative usage of TB in migrant healthcare provision.

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Delivery of care for migrants: balancing different languages, cultures, and health literacy levels

Migrant patients are vulnerable in ways local patients are not. They may

experience poor health status and face linguistic, bureaucratic, social, and cultural

barriers when accessing primary and specialised care, especially upon arrival. To

illustrate, migrants often face violence before, during and after their migratory

journeys, putting them at a higher risk of experiencing mental health issues

(Carruth et al.¸2021; MHealth4All, 2022). They must live and function in a

foreign community where a different language is spoken, and it has been

demonstrated that low levels of language proficiency affect health outcomes and

even use of services (Njoki-Yli Panula and Racasag-Niemi, 2020). Additionally,

migrant patients follow unfamiliar (administrative) procedures to navigate the

host system for referrals, follow-up visits or medication. This is further

exacerbated for patients with irregular status and/or constraints, such as

housing, education, income, or employment situation. Another thing to consider

is that migrant patients potentially have their own set of health beliefs, including

relying on traditional healing specialists, as opposed to biomedical practitioners,

and varying interpretations of symptoms, treatments, or attitudes to self-care

(Juckett, 2013; Patel et al., 2021). These elements translate into dissimilar levels

of health literacy, which is reportedly lower in migrants (Wernly et al., 2020;

Njoki-Yli Panula and Racasag-Niemi, 2020; Zdanuczyk, 2022).

Health literacy is defined as the patient’s ability to obtain, understand, and use

the information required to make wise health choices (Kimbrough, 2007). This

includes, but is not limited to, understanding health promotion materials, patient

information leaflets, informed consents, and instructions given by clinicians.

Language and access to education play an important part in health literacy, but

also the idiosyncratic cultures and beliefs surrounding health, as these aspects

affect how (often) migrant patients utilise care and preventive services, interact

with providers, perceive medical needs, understand oral or printed instructions,

and adhere to medical recommendations (Kalmanek, 2020; Paasche-Orlow and

Wolf, 2007). Consequently, optimal health literacy involves adequate health

promotion and disease prevention, whereas patients with poor health literacy fail

to understand and interpret medical information (linguistically or culturally) and

may experience shame and discomfort asking for additional information

(Zdanuczyk, 2022) or even avoid appointments due to fear or stigma associated

Cristina Álvaro Aranda

with poor comprehension levels (Drebold, 2020). Insufficient health literacy is

thus associated with health disparities, poor outcomes and increased health

system utilization and expenditure (Hersh et al., 2015; Wu et al., 2013; Lynch

and Franklin, 2019). Lastly, health literacy also affects how migrant patients

navigate the heath institutions (Zdanuczyk, 2022), as bureaucratic procedures

may vary from one country to another.

It should be noted that health literacy is not merely a patient-related

phenomenon and more recent definitions expand the emphasis on the individual

to include the role of institutions. In this sense, the Healthy People 2030

Framework distinguished between personal and organizational health literacy,

the latter being understood as “the degree to which organizations equitably

enable individuals to find, understand, and use information and services to

inform health-related decisions and actions for themselves and others” (ODPH,

2022, para. 3). This means that responsibility for health literacy includes

professionals and organizations offering health services and information (ibid.),

which calls for health-based institutions to communicate relevant information

clearly and sensibly, beyond one’s proficiency in the host country language

(Zdanuczyk, 2022). Since literacy assessment plays a major role in the success of

patient-clinician communication (Kimbrough, 2007) and migrant patients

usually do not share the provider’s language, the teach-back method (TB) and

the provision of healthcare interpreting services and intercultural mediation are

useful strategies to facilitate delivery of care in multilingual, multicultural

appointments. Both concepts will be addressed in the next sections as part of

our theoretical framework.

Introducing the teach-back method: usage and advantages

TB is a health-literacy-informed strategy by which patients describe in their own

words the information presented and, when comprehension is not

demonstrated, it allows clinicians to reteach or modify teaching (Yen and

Leasure, 2019; Vianin, 2021). This can be done in one visit or across several ones

(Mendoza, 2018). From a linguistic viewpoint, TB utterances can be considered

illocutionary and perlocutionary speech acts as defined by Austin (1962), since

they entail uttering sentences in a given context (medical) for a particular purpose

(assessing the patient’s understanding) and seeking a certain response from the

addresses (convincing or persuading patients to do or realise something

concerning their health status). Underlying is the fact that professional

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

interpreters must be capable of understanding the speaker’s wilfulness beyond

the linguistic level, so they can create a communicate response in listeners similar

to the one which would occur if sharing the same language (Pöchhacker, 2004).

According to the Agency for Healthcare Research and Quality (AHRQ, 2020),

TB should be utilized in high-risk clinical situations (i.e., scenarios requiring

immediate attention to avoid adverse events among patients), including

discharge, medicine reconciliation, informed consent, and Emergency

Department or surgical care. In such contexts, patients must be able to explain

in their own words: 1. the diagnosis and health problem for which they require(d)

assistance, 2. the nature of the necessary service, treatment, or procedure, and 3.

worsening symptoms and how to act (Tamura-Lis, 2013).

When using the teach-back method in patient education, it is important for

clinicians to emphasise that their goal is to check their own ability to explain

health information, rather than testing the patient’s knowledge (Mahramus et al.,

2014; AHRQ, 2020). To do so, providers must create a shame-free environment

in which plain language and encouraging requests facilitate understanding and

promote questions (Yen and Leasure, 2019; Slater et al., 2017; Mendoza, 2018).

Thus, asking “do you understand?” or “do you have any doubts?” is not

advisable, as patients will answer “no” due to fear, lack of literacy or intimidation

(Weiss, 2007). Instead, it is preferrable to resort to more open statements that

give patients an opportunity to interact actively, such as “We covered a lot today

and I want to make sure that I explained things clearly. So let’s review what we

discussed. Can you please describe the 3 things you agreed to do to help you

control your diabetes?” (AHRQ, 2020). Additionally, information overload must

be avoided by using “chunk and check”, which consists in delivering small

blocks of information followed by TB before proceeding to the next topic

(Brega et al., 2015).

Previous research supports using TB to reduce hospital readmission rates and

improve patients’ satisfaction, immediate and short-term knowledge retention,

adherence to treatment, and self-management of the disease, including

supervising and recognising symptoms, scheduling follow-up appointments,

using medical devices, and following dietary or medication instructions (Ha

Dinh et al., 2016; Mahajan et al., 2020; Mahramus et al., 2014; Mendoza, 2018;

Oh et al., 2021; Slater et al., 2017; Tamura-Lis, 2013). The advantages offered by

Cristina Álvaro Aranda

TB relate to research suggesting that patients tend to forget information or

memorise it incorrectly, thus being unaware of their lack of understanding and

giving providers a false sense of the latter, which is more noticeable for patients

with low literacy or from cultures within which is unthinkable to interrupt or

question people in positions of authority or knowledge (Morony et al., 2017; Ha

Dinh et al., 2016; Pietrzykowski and Smilowska, 2021; van der Giessen et al.,

2021). For this reason, it becomes imperative that providers initiate the

conversation and ask open-ended questions, as patients may be reluctant to do

so (Slater et al., 2017). In language-discordant consultations, this will be ideally

performed through or together with an interpreter.

Introducing healthcare interpreting

Healthcare interpreting is an umbrella term covering activities to support

bilingual health communication between patients, doctors and other health

practitioners or administrative staff (Davitti, 2019). Despite its widespread usage

and increasing demand, healthcare interpreting has not acquired professional

status to date, and the professional duties and boundaries of healthcare

interpreters, which sometimes merge with those of intercultural mediators, are

yet to be defined (Álvaro Aranda and Lázaro Gutiérrez, 2022). It is so much so

that some authors suggest merging both profiles into a single profession

encompassing both interpretation and mediation tasks (Grupo CRIT, 2014).

Similarly, over the years research has demonstrated that the role of interpreters

is not limited to strictly interpreting word for word, as they play a critical role

given their unique position in the encounter, and thus should be welcomed and

empowered as members of the care team that fully participate in interactions to

ensure patient safety (AHRQ, 2020). This resonates with the Theory of Sense

defended by Seleskovitch (1977), which stipulates that the speakers’ intended

meaning (or sense) must be preserved beyond the linguistic level, and this gives

interpreters a great deal of latitude to convey meanings, rather than words. It

also paves the way for interprofessional collaboration. For example, as part of

the assistance team, healthcare interpreters in Spain follow the principles of

beneficence and non-maleficence and are encouraged to contribute to attain

health outcomes, which may include lowering the linguistic register, engaging in

small talk, or explaining cultural aspects (Álvaro Aranda, 2020; Álvaro Aranda

and Lázaro Gutiérrez, 2022). In a similar vein, Álvaro Aranda et al. (2021) state:

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Healthcare interpreters must be considered as co-healthcare professionals

and allies valuable to the healthcare team. It must be understood that

healthcare interpreters are performing roles and functions in the

consultation that doctors do not need to overlap, but rather benefit from

to provide high quality care to patients. Doctors and patients need to learn

to work together, sharing power and responsibilities, as they both strive to

ensure the patients’ well-being from different, yet complementary, points

of view (no page).

Considering the above, Schreiber et al. (2019) pinpoint the need for clinicians to

engage interpreters in interactions to ensure allophone patients have understood

complex instructions and are competent to make health decisions. One way

doctors can achieve this is using TB through an interpreter, which is the main

focus of this study (Brega et al., 2015; Sappleton et al., 2022). However, and as

mentioned in the introduction, few studies explore TB in interpreter-mediated

medical interactions. Among this limited body of research, Drebold (2020)

focused on group orientation workshops for refugees including social and

healthcare settings in which TB was used to test information recall. When

interpreters participated, session moderators did not find TB optimal, since

discussions took too long, and attention shifted from the patients’ understanding

to the interpreters’ (ibid.). Related to this, Matsumoto (2017) suggested that

migrant patients may feel confused when clinicians use TB, as they could feel

they are asked to repeat the information to the interpreter, not back to the

provider. In Matsumoto’s opinion, this could be avoided if the interpreter

explains purpose and context: “The doctor is now asking you to describe how

you would take the medications to make sure he/she has explained it properly

to you” (ibid., p. 205).

For their part, Hommes et al. (2018) suggested that providers usually overlooked

using TB with deaf and hard of hearing patients to ensure understanding when

interpreters were involved. Similarly, but in an antenatal setting, Riggs et al.

(2021) found that midwifery staff rarely used TB with patients, mostly because

there was no additional time allocated for interpreter-mediated encounters.

Another thing to highlight is that participants in Riggs et al. (2021) reported

differing opinions. Whilst the midwife believed that information was understood

by patients using TB, the interpreter indicated that patients just repeated back

Cristina Álvaro Aranda

what they heard without comprehending medical terms (e.g., colostrum). More

importantly, the provider misinterpreted the patients’ laugh as a sign of

amusement, but the interpreter explained that smiling and laughter are culture-

bound elements involving nervousness and embarrassment. This implies that

TB can lead to misunderstandings in cross-cultural settings and the interpreter’s

presence is, thus, essential.

Methodological approach

The aim of this exploratory and descriptive study is to gain an understanding of

TB usage in language-discordant, interpreter-mediated healthcare interactions.

To do so, we isolated examples of TB in a multilingual dataset of interactions

involving a healthcare interpreter, which were registered in 2017 in a Madrilenian

(Spain) public hospital that accommodates an onsite team of healthcare

interpreters (Álvaro Aranda, 2020). Drawing on the literature review, selection

of TB usage was based on detecting prompts aiming to evaluate the patients’

knowledge after providing (health) education, by asking them to explain in their

own words what they had understood (Mahramus et al., 2014; Slater et al., 2017).

Method of analysis

As explained earlier, communicative events including TB were selected as single

units of analysis (or cases). Following Lázaro Gutiérrez’s (2018) analysis of

medical consultations involving foreign victims of gender-based violence, we

combined the principles of case study research and conversation analysis to

construct our methodological framework. On the one hand, case study research

allows exploring, explaining, and describing specific issues or phenomena within

their real-life environment and with their contexts (Stake, 1995; Yin, 2009). This

research strategy places emphasis on the understanding of a social event, rather

than on theory testing or controlling variables (Meyer, 2016). On the other hand,

conversation analysis involves “examination of language in interaction (…) and

how social action is brought about through the close organisation of talk”

(Antaki, 2011: p. 1-2). It studies both informal and formal interactions and

examines the configuration of conduct across settings of understanding and

production (Pomerantz and Fehr, 2011).

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Data collection and ethical considerations

The study was carried out with an authorisation of the University of Alcalá

(Madrid, Spain) and the board of the participating team of interpreters. Data

were drawn from direct observation through a structured protocol sheet and

fieldnotes (Flick, 2009). This allowed us to manually write down pertinent

excerpts, which provided the basis for data analysis, as interactions could not be

recorded due to privacy issues and institutional constraints. In addition, the

researcher obtained oral informed consent from all participants (i.e., patients,

interpreters, hospital staff) before joining the interactions, which was

conveniently registered. More precisely, participants received background

information about the study and were informed about guaranteed confidentiality

and their right to withdraw without providing any reason at any time. When

faced with communication barriers, we made use of interpreters to obtain

consent from allophone patients.

Participants

Five healthcare interpreters consented to participate in the study. They were

assigned a unique identification code to guarantee anonymity (e.g., Interpreter 1)

and completed a registration form, which included education, years of

professional experience and demographic information (see Table 1). Four

participants had no work experience. They were still completing their internships

as part of the curriculum of the MA in Intercultural Communication, Public

Service Interpreting and Translation at the University of Alcalá, Spain. This

programme contains a module focusing on healthcare interpreting and

translation, which combines theoretical lectures and practical exercises to

examine intercultural mediation, interpreting strategies, ethical dilemmas, codes

of ethics and terminology, amongst other aspects (Álvaro Aranda et al., 2021).

Interpreter 1, however, had four years of working experience in the field and

had received on-the-job training in healthcare interpreting and intercultural

mediation, Spanish administrative procedures in national and local healthcare

institutions, ethical principles, specialised terminology, and diseases regularly

treated at the hospital where the study was conducted.

Cristina Álvaro Aranda

Gend

Age

National

ity

Employ

ment

status

Working

language

Training in

healthcare

interpreting

Professional

experience in

healthcare

interpreting

Inter

prete

r 1

Fema

Spanish

Staff

interpret

Spanish

<>Fren

ch/Engli

sh/Arab

On-the-job

training (1

month)

4 years

Inter

prete

r 2

Fema

Spanish

Intern

Spanish

<>Fren

MA (2

months)

Inter

prete

r 3

Fema

Spanish

Intern

Spanish

<>Fren

MA (2

months)

Inter

prete

r 4

Fema

Spanish

Intern

Spanish

<>Fren

MA (2

months)

Inter

prete

r 5

Male

Spanish

Intern

Spanish

<>Fren

MA (2

months)

Table 1. Profile of healthcare interpreters (n=5)

As detailed elsewhere (Álvaro Aranda, 2021), interpreters of the sample

interacted with different hospital staff (including doctors, nurses, administrative

personnel, ward clerks, janitors, x-ray, and ultrasound technicians) and allophone

patients facing communication needs. Patients were usually male, Sub-Saharan

economic migrants (92.65 %) aged between 15-30 years (58.82 %) who targeted

Spain either as their first stop or as their destination in Europe. Most patients

were mother tongue speakers of African languages, but French served as a lingua

franca in most events, as this language enjoys official status in the patients’

countries of origin due to past colonization.

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Analysis

Following the selection criteria earlier described, we identified a total of 12

interactions in which TB is present. A preliminary observation that can be drawn

from our dataset is that communicative events are classified into two groups: a

first group of interactions involving patient, interpreter, and healthcare providers

(e.g., medical consultation) and a second group involving just patient and

interpreter (e.g., walking patients to the exit). Figure 1 shows specific

information. In any case, it is essential to highlight that TB is always initiated by

interpreters (12 events, 100%).

Figure 1. TB usage per type of participants

In our dataset, we can observe two different scenarios in which TB is used: mid-

consultation (5 events, 41.7%) and post-consultation (7 events, 58.3%). TB is

always employed as a communication tool (3 events, 100%) whilst the medical

consultation is taking place in interpreter-patient-healthcare provider

9 (75%)

3 (25%)

Interpreter-patient Interpreter-patient-healthcare provider

Cristina Álvaro Aranda

interactions. Contrarily, encounters involving just patient and interpreter occur

both mid- (2 events, 22.2%) and post-consultation (7 events, 77.8%). Dyadic

encounters between patient and interpreter are observed when the doctor leaves

the consultation room momentarily before the session comes to an end (i.e.,

mid-consultation) or, alternatively, when interpreters accompany patients to

schedule follow-up appointments, walk them to the exit, or answer their

questions, despite the medical consultation being finished and the healthcare

provider not being present anymore (i.e., post-consultation).

Furthermore, topics evaluated by TB include general descriptions and/or

worsening symptoms of the patient’s condition (6 cases, 50%), instructions to

perform additional testing, such as stool collection (3 cases, 25%), and, finally,

revising patient’s schedules to ensure they know the dates and locations of their

future medical appointments (3 cases, 25%).

Presentation of cases

This section examines two illustrative cases from our dataset: I. an Urology

consultation and II. a Tropical Medicine Consultation. They were selected

because they are thought to represent a wider number of cases that can be

extrapolated, replicated, and validated in other settings and organizational

contexts (Seawright and Gerring, 2008). Following the principles of case-study

research, we proceed to describe each case in-depth and interpret the observed

interactions, without attempting to generalise our insights. Thus, we do not

intend to produce scientific generalisations, but we aim for naturalistic

generalisation and transferability, that is, to offer findings that can be applied to

other cases (Gomm et al., 2000).

Concerning data presentation, patients communicate in French, healthcare

providers are native speakers of Spanish, and healthcare interpreters switch

between both languages as interactions unfold. To facilitate understanding and

research dissemination, excerpts are translated into English by the author, who

holds a PhD in Modern Languages and Translation. Body language and actions

appear in italics between brackets and (Interpretation to “language”) refers to

close renditions (Wadensjö, 1998).

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Case 1: Tropical Medicine consultation

Case 1 is a Tropical Medicine consultation involving patient, doctor, and

interpreter. Although more interpreters are present as spectators, we will focus

solely on Interpreter 1, as she is the only one that resorts to TB. The doctor is

an Argentinian woman specialised in Tropical Medicine, whilst the patient is a

Guinean male infected with Hepatitis B and tuberculosis who attends a follow-

up visit to evaluate his adherence to tuberculosis treatment and, subsequently,

prescribe a new one.

The patient is concerned about the possibility of transmitting Hepatitis B to his

children and asks the doctor several times for a cure. The doctor, however,

repeats that there is no cure available, since providers rely on vaccinations during

childhood for prevention, but reinforces that his partner can get vaccinated

before having unprotected sexual intercourse. When the patient nods, the doctor

proceeds to prescribe the new treatment and informs him that they need to

monitor his liver function routinely to ensure it does not deteriorate. Since the

patient does not seem satisfied with the doctor’s previous explanations and

continues repeating the same questions, the provider leaves the consultation

room momentarily in search of a more experienced colleague that can assist her.

The following interaction occurs:

Excerpt 1

(…)

Interpreter 1: Écoute, il y a deux types de personnes : celles qui surmontent la

maladie et celles qui ne le font pas. Mais dans les deux cas, la maladie est là. Dans

ton cas, ton corps contrôle la maladie et tu n'as pas besoin des médicaments, mais

elle est là et c'est pour ça que tu peux la transmettre. Quand tu veux avoir des

enfants, tu fais venir ta femme ici pour la vacciner pour que la maladie ne soit

pas transmise à tes enfants. Si nous sommes vaccinés, nous sommes protégés. Si

nous ne sommes pas vaccinés, nous ne sommes pas protégés, et nous pouvons

transmettre la maladie. Alors... tu es malade ? (Look, there are two types of

people: those who overcome the disease and those who do not. But in both cases,

the disease is there. In your case, your body controls the disease and you don't

need to take medicine, but it's there and that's why you can transmit it. When you

want to have children, you bring your wife here to vaccinate her so that the

disease is not transmitted to your children. If we are vaccinated, we are protected.

Cristina Álvaro Aranda

If we are not vaccinated, we are not protected, and we can transmit the disease.

So... are you sick?)

Patient: Oui (Yes)

Interpreter 1: Non, si tu étais malade, tu aurais ces symptômes : fièvre, fatigue,

nausées... Donc, es-tu malade ? (No, if you were ill, you would have these

symptoms: fever, fatigue, nausea... So, are you sick?)

Patient: Non (No).

Interpreter 1: Bien sûr. Es-tu malade ? (Of course. Are you ill?)

Patient: Non (No)

Interpreter 1: As-tu un virus transmissible ? (Do you have a transmissible virus?)

Patient: Oui (Yes)

[The doctor returns with a colleague]

(…)

As we can see in Excerpt 1, TB occurs mid-consultation whilst the provider is

not present. More precisely, the interpreter seizes the opportunity to provide

health information to the migrant patient in a more understandable manner. In

so doing, she summarises the points covered by the doctor during the

consultation and presents them in a way accessible to the patient, thus

transmitting sense instead of an exact word-for-word rendering (Seleskovitch,

1977). Whilst the doctor is absent, Interpreter 1 checks the patient’s level of

understanding through TB before the clinician arrives accompanied by a senior

doctor. In this case, TB aims to help the patient comprehend his health problem

and how to act accordingly (Tamura-Lis, 2013).

However, the interpreter fails to create a distended environment, as she asks

closed yes/no questions, instead of giving the patient the chance to demonstrate

his knowledge and explain in his own words what he has understood (Mahramus

et al., 2014). It could be argued that this is a more straightforward, save-timing

strategy to assess the patient’s understanding, but it should not be overlooked

that he may feel intimidated or judged (Weiss, 2007), which could give the

interpreter the false impression that he has indeed understood and internalised

health information (Morony et al., 2017; Ha Dinh et al., 2016; Pietrzykowski and

Smilowska, 2021; van der Giessen et al., 2021). Although Interpreter 1 informs

the providers of the conversation that has occurred in their absence when they

return, TB only works to a certain extent in Excerpt 1, since at this point there

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

is no certainty that the patient has no additional doubts about his condition and

treatment.

The medical consultation continues, and the senior doctor provides health

information to the patient, trying to clarify his doubts about his diagnosis and

treatment whilst the other clinician observes. Notwithstanding this, the patient

is still confused, and Interpreter 1 raises her hand to halt the conversation and

intervene:

Excerpt 2

Interpreter 1: Él está entendiendo lo contrario. Cree que el tratamiento es para

proteger su hígado de la hepatitis B (He is understanding the opposite. He

believes that the treatment is to protect his liver from hepatitis B)

Senior doctor: No, la pastilla es para controlar la tuberculosis, que puede afectar

al hígado, por eso le haremos análisis. La hepatitis B es otra cosa (No, the pill is

to control tuberculosis, which can affect the liver, that’s why we’ll run some tests.

Hepatitis B is something else)

(Interpretation to French)

Interpreter 1: Tu as deux choses : l'hépatite et la tuberculose. Le traitement que

tu prends est pour la tuberculose, qui n'a rien à voir avec l'hépatite. Alors, (name

of patient), à quoi sert les médicaments ? (You have two things: hepatitis and

tuberculosis. The treatment you are taking is for tuberculosis, which has nothing

to do with hepatitis. So, (name of patient), what is the medicine for?)

Patient: Pour la tuberculose (For tuberculosis)

Interpreter 1: Pour quoi tu vendra ici ? Pour voir quoi ? (What are you coming

here for? To see what?)

Patient: Le foi (The liver)

[The interpreter nods and looks at the doctors]

Interpreter 1: Creo que ya está (OK, I think that’s it).

Senior doctor: Vale, pues vamos fuera y le damos los volantes de las citas y demás

(OK, so let’s go outside so we can give him his referral notes and stuff)

(…)

Cristina Álvaro Aranda

As shown in Excerpt 2, the doctor’s informative and prescriptive intentionality

is not reaching the patient, which implies that the desired response is failing to

be transmitted. Thus, Interpreter 1 announces that the patient does not

understand his disease conditions and plan of care. This leads the senior doctor

to provide an additional explanation, which the interpreter appropriately renders

into French. However, she decides to assume a much more central role and

poses several questions to evaluate the patient’s comprehension. Once she is

satisfied with the answers, she turns to the doctors and indicates that he has

allegedly interiorised the health education and instructions provided. Instead of

double-checking this herself, the senior doctor trusts the interpreter’s criteria

and moves on to subsequent stages of the consultation. In line with AHRQ’s

guidelines (2020) and authors such as Álvaro Aranda et. al. (2021), Interpreter 1

is welcomed as a member of the care team that contributes to attain health safety

and outcomes by means of TB.

Case 2: Urology consultation

Case 2 includes TB usage in a Urology consultation involving patient, provider,

and Interpreter 1. Interpreter 4, who shadows her more experienced colleague,

is also present, but she remains silent throughout the interaction. Concerning

the remaining participants, the patient is a nineteen-year-old Guinean male

patient with a varicocele that attends a follow-up medical visit to get the results

of an ultrasound scan and a spermiogram, whilst the urologist is male native

speaker of Spanish with an acceptable command of French. Nevertheless, the

interpreter facilitates communication to ensure there are no misunderstandings

or cultural nuances that may hinder the session.

Before communicating the results, the clinician elicits the patient’s pain history

and inquiries about any differences in the size of his varicocele. Throughout the

consultation, the clinician uses technical language (e.g., infertility, sperm). The

interpreter, who has worked with the patient before and is aware of his low level

of health literacy, frequently asks the patient if he understands the medical terms

employed by the clinician. When he admits he does not, the interpreter informs

the doctor so he can lower the register. Excerpt 3 takes place in this context:

Excerpt 3

(…)

Doctor: Vale, dile que el seminograma está bien (OK, tell him that the

seminogram is normal).

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Interpreter 1: Le médecin dit: “Dis-lui que le spermogramme est bon”. (The

doctor says: OK, tell him that the seminogram is normal)

[The patient nods]

Doctor: Bueno, como parece que el seminograma está bien de momento no va a

hacer falta operar el seminograma. (Well, as it seems that the seminogram is

normal there’s no need to operate the seminogram for now)

Interpreter 1: Perdona, ¿has dicho operar el seminograma? (Excuse me, did you

say operate the seminogram?)

Doctor: El varicocele (The varicocele).

(Interpretation to French)

Interpreter 1: (Name of patient), avez-vous compris ? Répétez-le, répétez ce que

vous avez compris (Name of patient, do you understand? Repeat it, repeat what

you have understood)

Patient: Oui, comme la douleur n'est pas grave, je ne me fais pas opérer (Yes, as

the pain is not serious, I don’t need to have surgery)

Interpreter 1: Le he preguntado si lo ha entendido y dice que como el dolor no

es grave no hace falta que se opere (I asked him if he has understood and he says

that he doesn’t need to have surgery because the pain is not serious)

Doctor: No, no, ese no es el criterio. Quiero decir que como los resultados del

análisis están bien no hace falta que se opere (No, no, that’s not the criteria. What

I want to say is that there’s no need for him to have surgery because the results

of the analysis are normal)

(…)

Excerpt 3 is a perfect example of doctor-interpreter interprofessional

collaboration to accommodate the patient’s communicative needs and health

literacy level. Contrary to Excerpt 1, in which the interpreter poses yes/no

questions, TB is delivered by means of a more open statement: “Repeat it, repeat

what you have understood.” In line with the AHRQ’s high-risk scenarios (2020),

Interpreter 1 gives the patient a chance to demonstrate his understanding when

surgical care is discussed. This is done before proceeding to the next topic of the

consultation, thus using “chunk and check” (Brega et al., 2015). Since the

patient’s answer reveals a lack of understanding, the doctor clarifies the surgery

Cristina Álvaro Aranda

eligibility criteria, thus modifying previous teaching (Yen and Leasure, 2019;

Vianin, 2021). In this case, TB serves as an effective strategy successfully

implemented to gauge the patient’s understanding and act accordingly.

Subsequent phases of the consultation include a description of worsening

symptoms, pain management medication and future follow-up visits. Once the

session is terminated, Interpreter 1 accompanies the patient to schedule his next

appointment. Excerpt 4 is extracted from this stage:

Excerpt 4

Interpreter 1: Tu as tout compris, (name of patient), tu as des questions ? (Did

you understand everything (name of patient), do you have any questions?)

Patient: No, no (Non, non)

Interpreter 1: Vale (OK) (To the doctor) Muchas gracias, hasta luego (Thank you

very much, see you)

Doctor: Hasta luego (See you)

[The interpreter and the patient walk to the administration desk]

Interpreter 1: Le prochain rendez-vous sera ici dans deux ans. Qu'est-ce que le

médecin t’a dit que tu dois utiliser quand ça fait mal ? (The next appointment will

be here in two years. What did he doctor tell you that you must use when it

hurts?)

Patient: Des slips (Briefs)

Interpreter 1: Oui (Yes)

Patient: Mais… Qu’est ce qui se passe? Je ne peux pas prendre des médicaments

? (But… What happens? I can’t take any medication?)

Interpreter 1: Si, tu peux (Yes, you can)

Patient: Lequel ? (Which one?)

Interpreter 1: Je t’ai demandé si tu avais des questions et tu as dit non. Tu ne

peux pas quitter la salle de consultation avec des questions, tout doit toujours

être clair. On va y retourner (I asked you if you had questions and you said no.

You can’t leave the consultation room with questions, everything must always be

clear. We’re going back)

Excerpt 4 readily illustrates culturally-based health attitudes preventing patients

to interrupt the doctor or admit they lack understanding (Morony et al., 2017;

Ha Dinh et al., 2016; Pietrzykowski and Smilowska, 2021; van der Giessen et al.,

2021). Interestingly, Interpreter 1 gives the patient the chance to ask questions

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

but, following Weiss (2007) and Zdanuczyk (2022), he refuses to do so because

he either feels fear, embarrassment, or intimidation in the presence of the doctor.

Both urologist and interpreter thus fail to create a shame-free environment

within which the patient is comfortable enough to ask questions without being

encouraged to (Yen and Leasure, 2019; Slater et al., 2017; Mendoza, 2018).

Nevertheless, Interpreter 1 uses TB again once she is alone with the patient. On

this occasion, she enquires about specific topics, and, in the absence of the

clinician, the patient poses a question concerning his medication. Interpreter 1

refuses to reply and, instead, returns to the consultation room to ask the doctor

so he can solve the patient’s doubts.

Discussion

The central goal of this paper is to broaden the knowledge of TB usage in

interpreter-mediated, healthcare consultations. We combine the principles of

case-study research and conversation analysis to examine a dataset of

multilingual, multicultural events that occurred in a hospital in Madrid, Spain.

In line with the literature findings, patients in our dataset have a low level of

health literacy (Caplin and Saunders, 2015; Tamura-Lis, 2013). This does not

solely apply to general knowledge about their condition (6 cases, 50%), but also

regarding how to perform additional testing (3 cases, 25%) and navigate

administrative procedures in the host health institution (3 cases, 25%). Thus, our

proposal for scenarios in which TB is employed serves to illustrate the

complexity of healthcare delivery in migrant care.

Furthermore, our findings indicate that TB is decisive for patient understanding

and compliance of treatment, which resonates with previous literature on the

topic (e.g., Mahramus et al., 2014; Mendoza, 2018). In our dataset in general, and

in the two cases presented in particular, interpreters always initiate TB usage

(Excerpts 1, 2, 3, 4), even in the absence of the physician (9 cases, 75%), both

mid- (2 events, 22.2%) and post-consultation (7 events, 77.8%). This engages

with research promoting interpreters as members of the care team that

participate actively to ensure patient safety, patient autonomy, and positive

health outcomes (AHRQ, 2020; Schreiber et al., 2019; Álvaro Aranda et al.,

Cristina Álvaro Aranda

2021), but contradicts protocols suggesting clinicians to initiate TB and ask

open-ended questions themselves (Slater et al., 2017).

Providers thus overlook using TB when interpreters are involved, an observation

also present in other studies (see Hommes et al., 2018; Riggs et al., 2021). As

migrant patients usually avoid asking questions due to fear, intimidation, or

embarrassment (Weiss, 2007), it is essential to promote clinician-interpreter

interprofessional collaboration. However, TB in interpreter-patient-doctor

encounters is solely observed in 3 events (25%). This leads us to believe that,

when it comes to TB, doctors and interpreters of the sample are not familiar

with collaborative practices.

For the reasons detailed above, it is important to underline that successful usage

of TB requires a multifaceted, coordinated approach that should be taught in

interprofessional training modules and/or ongoing education. In our dataset,

doctors avoid using TB with migrant patients and interpreters often resort to

“yes/no questions” (Excerpt 1), instead of more open statements as suggested

in the literature (AHRQ, 2020; Weiss, 2007). In this sense, Excerpt 3 could be

taken as a point of departure to develop more sophisticated training proposals.

More precisely, the interpreter invites the patient to teach back the health

education received and informs the doctor of his response. This gives the

clinician a chance to act and provide additional explanations and corrections in

a culturally appropriate fashion, always aided by the interpreter.

Our findings can be understood as a plea for interprofessional collaboration and

education. Health systems worldwide face daily pressures responding to

increasingly dynamic patient demographics and are tasked with implementing

culturally responsive practices in the delivery of care for patients with a migrant

background. In such context, understanding the workings of specific

environments of interpretation and the underlying techniques available (e.g., the

TB method) is essential to cover the aims of medical communication. Rather

than being disconnected from each other, universities and other education

institutions should offer a meeting ground for trainees from different, yet

interconnected, disciplines (in this case, students enrolled in Medicine and

Interpreting and/or Translation programmes).

This would be interesting to implement in universities offering both

programmes by introducing subjects combining theoretical principles from both

fields of knowledge (e.g., how to verify patients’ understanding through teach-

back, health literacy, cultural differences and varying perceptions of health and

self-management of illness, guidelines for working with healthcare interpreters,

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

etc.) and several practical activities in the shape of roleplays. These could be

structured around specific challenges in migrant healthcare delivery to test both

Medicine and Translation/Interpreting trainees (e.g., a patient who does not

understand how to measure his glucose levels). Ideally, students would practice

in small groups and, eventually, in front of the class to facilitate collective,

interdisciplinary reflection, which would be supervised by educators with

expertise and professional experience in Medicine and/or

Interpreting/Translation.

Conclusions

Recent definitions of health literacy underline the role of organizations in

providing accessible health information equitably to all individuals (ODPH,

2022). In our multicultural, multilingual societies, this undeniably includes the

provision of language services and culturally responsive communicative

strategies for patients with low educational levels, which include TB. In fact, TB

usage has the potential to improve healthcare delivery for migrant patients with

low literacy levels and, thus, contribute to the attainment of socially inclusive,

equalitarian societies. Due to the limited size of our sample (TB is used in only

12 events), results presented here cannot be generalised, but they could be tested

and replicated in different organizational contexts by other researchers

interested in TB, which is the aim of naturalistic generalisation or transferability

(Gomm et al., 2000). Potential lines for future research include the replication

of the study in different institutions to increment our dataset. In turn, new data

will serve to develop role play scenarios based on real situations and a wider

range of topics, and this will allow designing interprofessional education options

(and thus, collaborative practices) between future healthcare interpreters and

clinicians.

References

AHRQ (Agency for Healthcare Research and Quality). (2020). Improving patient safety

systems for patients with limited English proficiency. A guide for hospitals. [Online] [Accessed

Cristina Álvaro Aranda

on 2nd September 2022] https://www.ahrq.gov/health-literacy/professional-

training/lepguide/index.html

Álvaro Aranda, C., Lázaro Gutiérrez, R., and Li, S. (2021). Towards a collaborative

structure of interpreter-mediated medical consultations: Complementing functions

between healthcare interpreters and providers. Social Science & Medicine, 269.

https://doi.org/10.1016/j.socscimed.2020.113529

Álvaro Aranda, C., and Lázaro Gutiérrez, R. (2022). Functions of small talk in healthcare

interpreting: an exploratory study in medical encounters facilitated by healthcare

interpreters. Language and Intercultural Communication, 22(1), pp. 21-34.

https://doi.org/10.1080/14708477.2021.2024842

Álvaro Aranda, C. (2020). Formación y experiencia profesional como diferenciadores en la actuación

de intérpretes sanitarios: un estudio de caso desde la sociología de las profesiones [Unpublished

Doctoral Dissertation, University of Alcalá].

Álvaro Aranda, C., González, Ch., and Lázaro Gutiérrez, R. (2021). La enseñanza

bimodal de la interpretación sanitaria: Una experiencia docente en un máster

universitario en TISP. Lenguas Modernas y Traducción, 58, pp. 137-153. [Online]

[Accessed on 30th April 2023]

https://lenguasmodernas.uchile.cl/index.php/LM/article/view/66437

Álvaro Aranda, C. (2021). “I Don’t Know, I’m Just the Interpreter”: A first approach

to the role of healthcare interpreters beyond bilingual medical encounters. TRANS,

Revista de Traductología, 25, pp. 395-412.

https://doi.org/10.24310/TRANS.2021.v1i25.10128Antaki, C. (Ed.). (2011).

Applied conversation analysis: Intervention and change in institutional talk. Palgrave

Macmillan.

Austin, J. L. (1962). How to do things with words. Oxford University Press.

Brega, A.G., Barnard, J., Mabachi, N.M., Weiss, B.D., DeWalt, D.A., Brach, C.,

Cifuentes, M., Albright, K., and West, D.R. (2015). AHRQ Health Literacy Universal

Precautions Toolkit (2nd ed.). Agency for Healthcare Research and Quality. [Online] [Accessed

on 2nd September 2022] https://www.ahrq.gov/health-

literacy/improve/precautions/index.html

Caplin, M., and Saunders, T. (2015). Utilizing teach-back to reinforce patient education:

a step-by-step approach. Orthopaedic Nursing, 34(6), pp. 365-368. DOI

10.1097/NOR.0000000000000197

Carruth, L., Martínez, C., Smith, L., Donato, K., and Piñones Rovera, C. (2021).

Structural vulnerability: migration and health in social context. BMJ Global Health.

DOI 10.1136/ bmjgh-2021-005109.

Davitti, E. (2019). Healthcare interpreting. In Baker, M. and Saldanha, G. (Eds.),

Routledge encyclopedia of translation studies (3rd ed.). Routledge.

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Drebold, H. (2020). Improving health literacy of newly arrived refugees: A qualitative assessment of

the health-communication method Förstå Mig Rätt within the Swedish civic orientation [Master’s

degree project, Uppsala Universitet]

Flick, U. (2009). An introduction to qualitative research (4th edition). Sage.

Gomm, R., Hammersley, M., and Foster, P. (2000). Case study and generalization. In

Gomm, R.; Hammersley, M. and Foster, P. (Eds.), Case study methods. Sage.

Grupo CRIT. (2014). La práctica de la mediación interlingüística e intercultural en el ámbito

sanitario. Comares.

Ha Dinh, T.T., Bonner, A., Clark, R., Ramsbotham, J., and Hines, S. (2016). The

effectiveness of the teach-back method on adherence and self-management in health

education for people with chronic disease: a systematic review. JBI Database of

Systematic Reviews and Implementation Reports, 14(1), pp. 210-247. DOI 10.11124/jbisrir-

2016-2296.

Hersh, L., Salzman, B., and Snyderman, D. (2015). Health literacy in primary care.

American Family Physician, 92(2), pp. 118-124. [Online] [Accessed 8 September 2022]

https://www.aafp.org/pubs/afp/issues/2015/0715/p118.html

Hommes, R.E., Borash, A.I., Hartwig, K., and DeGracia, D. (2018). American Sign

Language interpreters perceptions of barriers to healthcare communication in Deaf

and Hard of Hearing patients. Journal of Community Health, 43(5), pp. 956-961

https://doi.org/10.1007/s10900-018-0511-3

Juckett, G. (2013). Caring for Latino patients. American Family Physician, 87(1), pp. 48-

54. [Online] [Accessed 30 August 2022]

https://www.aafp.org/pubs/afp/issues/2013/0101/p48.html

Kalmanek, J. (2020). An exploration of barriers and strategies for effective delivery of point-of-care

patient education in the refugee population. [Online] [Accessed 30 August 2022]

https://med.virginia.edu/

Kimbrough, J. B. (2007). Health literacy as a contributor to immigrant health disparities.

Journal of Health Disparities Research and Practice, 1(2), pp. 93-106. [Online] [Accessed

27 August 2022] https://digitalscholarship.unlv.edu/jhdrp/vol1/iss2/6

Kletečka-Pulker, M., Parrag, S., Doppler, K., Völkl-Kernstock, S., Wagner, M., and

Wenzel, T. (2021). Enhancing patient safety through the quality assured use of a

low-tech video interpreting system to overcome language barriers in healthcare

settings. Wiener Klinische Wochenschrift, 133(10). https://doi.org/10.1007/s00508-020-

01806-7

Cristina Álvaro Aranda

Lázaro Gutiérrez, R. (2018). Interpretación sanitaria para víctimas de violencia de

género. Panace@ XIX(47), pp. 96-105. [Online] [Accessed 30 August 2022]

https://www.tremedica.org/wp-content/uploads/n47-tribuna-4.pdf

Lynch, M.A., and Franklin, G.V. (2019). Health literacy: An intervention to improve

health outcomes. In Mullings, J., Thoms-Rodriguez, C.A., McCaw-Binns, A. and

Paul, T. (Eds), Strategies to reduce hospital mortality in lower and middle income countries

(LMICs) and resource-limited settings (pp. 11-34). IntechOpen.

Mahajan, M., Hogewoning, J.A., Zewald, J.J.A., Kerkmeer, M., Feitsma, M., and van

Rijssel, D.A. (2020). The impact of teach-back on patient recall and understanding

of discharge information in the emergency department: the Emergency Teach-Back

(EM-TeBa) study. International Journal of Emergency Medicine, 24(49).

https://doi.org/10.1186/s12245-020-00306-9.

Mahramus, T., Aragon Penoyer, D., Frewin, S., Chamberlain, L., Wilson, D., and Lou

Sole, M. (2014). Assessment of an educational intervention on nurses’ knowledge

and retention of heart failure self-care principles and the Teach Back method. Heart

and Lung, 43(3), pp. 204-212. https://doi.org/10.1016/j.hrtlng.2013.11.012.

Matsumoto, N. (2017). Patients’ experiences of communication support in Japanese-English medical

encounters [Doctoral Dissertation, The Australian National University].

Mendoza, T. (2018). Enhancing health literacy using teach back method to increase

patient adherence. Doctor of Nursing Practice (DNP) projects 144. [Online]

[Accessed 2nd September 2022] https://repository.usfca.edu/dnp/144.

Meyer, B. (2016). Case studies. In Angelelli, C. and James Baer, B. (Eds.), Researching

translation and interpreting (pp. 177-184). Routledge.

MHealth4All. (2022). [Online] [Accessed 8th September 2022]

https://www.mhealth4all.eu/

Morony, S., Weir, K., Duncan, G., Biggs, J., Nutbeam, D., and McCaffery, K. (2017).

Experiences of teach-back in a telephone health service. Health Literacy Research

Practice, 1(4), pp. 173-181. DOI 10.3928/24748307-20170724-01.

Njoki-Yli Panula, E., and Racasag-Niemi, J.B. (2020). Health literacy among adult immigrants

in Ostrobothnia [Bachelor’s thesis, Yrkeshögskolan Novia]. Theseus.

ODPH (Office of Disease Prevention and Health Promotion. (2022). History of health

literacy definitions. [Online] [Accessed 9th August 2022] https://health.gov/

Oh, E.G., Lee, H.J., Yang, Y.L., and Kim, Y.M. (2021). Effectiveness of discharge

education with the teach-back method on 30-day readmission: a systematic review.

Journal of Patient Safety, 17(4), pp. 305-310. DOI 10.1097/PTS.0000000000000596.

Paasche-Orlow, M.K., and Wolf, M.S. (2007). The causal pathways linking health

literacy to health outcomes. American Journal of Health Behaviour, 31(1), pp. 19-26. DOI

10.5555/ajhb.2007.31.supp.S19.

Examining Teach-back Strategies in Healthcare Interpreting through Case Study Research

Patel, H., Szkinc-Olsson, G., and Lennartsson Al Liddawi, M. (2021). A qualitative study

of nurses’ experiences of self-care counseling in migrant patients with heart failure.

International Journal of Nursing Sciences, 8, pp. 279-288. DOI

10.1016/j.ijnss.2021.05.004.

Pietrzykowski, T., and Smilowska, K. (2021). The reality of informed consent: empirical

studies on patient comprehension—systematic review. Trials, 22(1), p. 57. DOI

10.1186/s13063-020-04969-w.

Pitt, M.B., and Hendrickson, M.A. (2020). Eradicating jargon-oblivion—A proposed

classification system of medical jargon. Journal of General Internal Medicine, 35, pp.

1861-1864. DOI 10.1007/s11606-019-05526-1.

Pöchhacker, F. (2004). Introducing interpreting studies. Routledge.

Pomerantz, A., and Fehr, B.J. (2019). Conversation analysis: an approach to the analysis

of social interaction. In V. Dijk (Ed.), Discourse studies: A multidisciplinary introduction

(pp. 165-190). Sage.

Riggs, E., Brown, S., Szwarc, J., Nesvadba, N., and Yelland, J. (2021). Teach-back in

interpreter-mediated consultations: Reflections from a case study. Health Literacy

Research and Practice, 5(3), pp. e256-e261. DOI 10.3928/24748307-20210811-01.

Rousseau, C., and Frounfelker, R.L. (2018). Mental health needs and services for

migrants: an overview for primary care providers. Journal of Travel Medicine, 26(2).

DOI 10.1093/jtm/tay150.

Sappleton, K., Karmali, K., and Srivastava, R.H. (2022). Working with interpreters in

health care settings. In R.H. Srivastava (Ed.), The health care professional’s guide to cultural

competence (pp. 131-151). Elsevier.

Schreiber, J., Phillips, C., Bouassi, T., Humphreys, C., Kanhutu, K., Painting, M., and

Vasic, G. (2019). Guide for clinicians working with interpreters in healthcare

settings. Migrant and refugee’s women’s health partnership. Migrant and Refugee

Women’s Health Partnership. [Online] [Accessed 1st September 2022]

https://culturaldiversityhealth.org.au/

Seawright, J., and Gerring, J. (2008). Case selection techniques in case study research: a

menu of qualitative and quantitative options. Political Research Quarterly, 61(2), pp.

294-308. [Online] [Accessed 11th September 2022]

http://www.jstor.org/stable/20299733

Seleskovitch, D. (1977). Take care of the sense and the sounds will take care of

themselves or why interpreting is not tantamount to translating languages. The

Incorporated Linguist, 15, pp. 27-33.

Cristina Álvaro Aranda

Slater, B.A., Huang, Y., and Dalawari, P. (2017). The impact of teach-back method on

retention of key domains of Emergency Department discharge instructions. The

Journal of Emergency Medicine, 53(5), pp. e59-e65. DOI

10.1016/j.jemermed.2017.06.032

Stake, R.E. (1995). Investigación con estudio de casos. Ediciones Morata.

Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic

Nursing, 33(6), pp. 267-271. DOI 10.7257/1053-816X.2013.33.6.267.

van der Giessen J., Fransen, M.P., Spreeuwenberg, P., Velthuizen, M., van Dulmen, S.,

and Ausems M. (2021). Communication about breast cancer genetic counseling with

patients with limited health literacy or a migrant background: evaluation of a training

program for healthcare professionals. Journal of Community Genetics, 12, pp. 91-99.

DOI 10.1007/s12687-020-00497-x.

Vianin, M. (2021). Dispositionalism in musculoskeletal care: Understanding and integrating unique

characteristics of the clinical encounter to optimize patient care. Evolve Global Publishing.

Wadensjö, C. (1998). Interpreting as interaction. Routledge.

Weiss, B. (2007). Health literacy and patient safety: Help patients understand (2nd ed.). Chicago,

American Medical Association.

Wernly, B., Wernly, S., Magnano, A., and Paul, E. (2022). Cardiovascular health care

and health literacy among immigrants in Europe: a review of challenges and

opportunities during the COVID-19 pandemic. Zeitschrift fur Gesundheitswissenschaften,

30(5), pp. 1285-1291. DOI 10.1007/s10389-020-01405-w

Wu, J.R., Holmes, G.M., DeWalt, D.A., Macabasco-O'Connell, A., Bibbins-Domingo,

K., Ruo, B., Baker, D.W., Schillinger, D., Weinberger, M., Broucksou, K.A., Erman,

B., Jones, C.D., Cene, C.W., and Pignone, M. (2013). Low literacy is associated with

increased risk of hospitalization and death among individuals with health failure.

Journal of General Internal Medicine, 28(9), pp. 1174-1180 DOI 10.1007/s11606-013-

2394-4.

Yen, P.H, and Leasure, A.R. (2019). Use and effectiveness of the teach-back method in

patient education and health outcomes. Federal Practitioner, 36(6), pp. 284-289.

[Online] [Accessed 8 September 2022] https://www.mdedge.com/fedprac

Yin, R.K. (2009). Case study research. Design and methods (4th ed.). Applied social research

methods (Vol. 5). Sage.

Zdanuczyk, K. (2022). Is health literacy a defined risk factor? A literature review of

health literacy as it relates to immigrant populations in the US. International

Development, Community and Environment (IDCE). Online] [Accessed 8 September

2022] https://commons.clarku.edu/idce_masters_papers/256