Introduction

Among the European countries, France rates second (behind Germany) in terms of the number of asylum seekers entering the country [1]. The health status of migrants is often adversely affected by their vulnerable situation, and represents a major public health issue [2, 3]. The native language of many migrants is often not the language spoken in the country where they are arriving. These migrants, called “allophones”, have cited the language barrier as the greatest obstacle to accessing healthcare in their host country [4, 5]. Indeed, the language barrier prevents allophone patients from acquiring healthcare knowledge [6]. Furthermore, the doctor-patient relationship is founded on a feeling of security and trust in the healthcare provider [4], and therefore, allophone patients are at risk of communication difficulties that can lessen their satisfaction with care [7]. In this regard, interpreters provide a much-needed solution to the language problem, whether they are formal, i.e. a trained professional interpreter, or informal (family members or friends of the patient) [8]. However, it has been reported that informal interpreting is not always satisfactory for allophone patients in primary care [9]. In particular, errors in translation may incur substantial clinical risk, and are significantly more frequent with informal interpreters than with trained interpreters [10]. Professional interpreters therefore have a major role to play during medical consultations, from an ethical point of view (to enable informed consent to be obtained), in improving the quality of care and follow-up (especially for chronic diseases, psychiatry or prevention) and in economic terms [11, 12].

Because of the scarcity of interpreting resources, telephone interpreting services (TIS) have become widespread since they first appeared in the 1970s [13]. While TIS present certain advantages, namely convenience, ease of access to qualified interpreters, and cost-effectiveness [14], some situations may not be amenable to the use of TIS. Wang et al. highlighted at least three such situations, all related to healthcare management, namely conversations with high emotional content, conversations about life or death, and medical settings (especially mental health consultations) [15]. Moreover, the accuracy of interpreting performance decreases by phone compared to face-to-face situations, while interpreters are more likely to make strategic additions (i.e., giving additional information to contribute to cultural understanding, effective communication and strong rapport between participants) [13, 16, 17]. TIS also face other challenges related to technical difficulties (e.g., poor sound quality), lack of training (e.g., managing three-way communication over the phone), and working conditions (e.g., low pay and isolation) [14]. According to Gracia-García, “a good interpreter at a distance is better than a bad one up close or none at all” [18]. Nevertheless, in a systematic review, Joseph et al. concluded that current evidence does not suggest that any one particular mode of interpreting is superior to all others [19]. Given that TIS is a valuable service in a multicultural society, it deserves more attention in interpreter education, since it requires specific interpreting skills [20].

In France, the Regional Union of Independent Physicians in the Centre Loire region (URML des Pays de la Loire) has been providing interpreting services in the private-practice setting since 2017. It has also been providing interpreting services by telephone since 2018. On the basis of this experience, the Regional Union of Independent Medical Practitioners of the East of France (URPS Grand Est) decided to test a telephone-based interpreting service (TIS), initiated in October 2018. Physicians receiving allophone patients in consultation can contact the TIS free of charge, and be immediately put on to a professional interpreter. Two years after the introduction of this service, we sought to investigate how the allophone migrant patients perceive the use of this telephone-interpreting service during primary care consultations. As evidence from allophone migrant patients’ perspective is missing [21, 22], the insights provided could help to better integrate this service into the practice of general practitioners (GPs) and primary care practitioners.

Materials and methods

Results

A total of 32 people were identified and contacted to participate. Thirteen of these agreed to participate, but 3 of them failed to show up at the agreed time for the interview. Therefore thus, from September 2019 to January 2020, a total of ten interviews were held (i.e. one with each participating allophone patient). The interviews were held in a dedicated room at the accommodation centre, which was known to all participants, and was quiet and informal.

The characteristics of the participants are detailed in Table 1. The average duration of the interviews was 34 minutes (range 23 to 63 minutes).

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Table 1. Characteristics of the participants.

https://doi.org/10.1371/journal.pone.0264832.t001

Data from the interviews produced eight thought clusters related to the allophone migrants’ perception of the TIS. As shown in Table 2, these clusters were assembled to generate the following three major themes: (i) multi-level difficulties for allophone migrants in the healthcare pathway; (ii) the interpreter as the cornerstone of the doctor-patient relationship; and (iii) advantages and limitations of the TIS.

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Table 2. Summary of the themes derived from the interviews and clustering of the allophone migrants’ perception of the TIS.

https://doi.org/10.1371/journal.pone.0264832.t002

Being an allophone migrant: multi-level difficulties in the primary care pathwayOur findings revealed that the language barrier is present all along the migrant’s consultation pathway, namely before, during and after the consultation.

Before the consultation, the obstacle of trying to get an appointment can make migrants delay, or abandon their recourse to care, via two mechanisms. Firstly, the language barrier can make it technically impossible to make an appointment, unless a third party can provide assistance: ‘If I have a problem, or when I’m sick, the social worker has to make an appointment with the doctor’ (E2).

Second, the language barrier can prompt patients to fear that they will have difficulty making themselves understood during the consultation. Therefore, the patient will sometimes prefer to forego medical care rather than meet this difficulty head on, and the use of the TIS thus made it possible to get these allophone migrant patients in contact with the healthcare system at an earlier stage: ‘I was in difficulty, but I preferred not to consult the doctor because I had trouble expressing myself, making myself understood […] Now that there’s an interpreter, I’m more inclined to make an appointment with the doctor’ (E4).

During the consultation, the interpreter is necessary, not to say indispensable in guaranteeing optimal management. This makes it possible for allophone patients to give detailed explanations about their motive for consulting the doctor:

1. ‘If there hadn’t been an interpreter, we would have no use for a doctor’ (E1). ‘The interpreter can explain to the doctor what’s wrong with me’ (E3).

This also helps to avoid errors in management: ‘I tried to tell him I had a pain in my stomach, but I couldn’t. I must’ve been misunderstood because the doctor prescribed me medication for heart problems’ (E3).

The interpreter acts as a bridge between the doctor and the patient, enabling flow of information in both directions. This mutual comprehension is crucial at the time of the consultation to promote the therapeutic alliance between the doctor and the patient: ‘The interpreter is the tool that bridges the gap between me and the doctor, […] the tool that enables me to communicate’ (E7).

After the consultation, this comprehension conditions the follow-up management and also contributes to patient compliance:

1. ‘We understood each other much better [with the doctor]. He understood what I wanted, what I was asking as a patient’ (E8).
2. ‘The interpreter ensures that the doctor doesn’t get a wrong impression’ (E7).

Discussion

This study aimed to describe the perception of allophone migrant patients about the use of a telephone interpreting service (TIS) during a primary care consultation in France. Our results highlight the difficulties of allophone migrants throughout the primary care pathway (before, during, and after the consultation) and the role of the interpreter as the cornerstone of the doctor-patient relationship. However, the participants also pointed out some limitations of the use of TIS in this context.

The language barrier in healthcare has primarily been studied in the hospital setting, i.e. emergency admissions or during hospitalisation [7, 27, 28], with the focus often on an analysis of the costs versus the benefits [29, 30]. In order to avoid the emergency room becoming the only point of access to care for allophone migrants, ambulatory care in the community needs to be available to them, but few studies have investigated the utility of interpreting services in primary care. According to Bischoff and Denhaerynck, interpreting services help to optimize the patient’s healthcare pathway by facilitating access to primary care and prevention, and by reducing use of emergency services and futile complementary examinations [31]. Nevertheless, their study focused on health care costs, not on patient satisfaction or patients’ representations about the interpreting service. Our study provides complementary insights, since participants unanimously agreed that the TIS was useful, and helped to make the exchange of information easier, ensuring that the information was exhaustive for both parties. According to our results, TIS makes it possible to facilitate access to primary care for allophone patients.

Our results revealed that overcoming the language barrier also made it possible for allophone patients to address other motives for consultation, such as potential psychological disorders. By sharing a common language, or even a common dialect, with someone who comes from the same country, or even the same ethnic group, the migrant and the interpreter share certain cultural specificities that may have an influence on the patient’s management [32, 33]. A systematic review by Bauer and Alegría about the impact of interpreting on the quality of psychiatric care shows that professional interpreters improve disclosure and attenuate difficulties. Indeed, evaluation in a patient’s non-primary language may lead to incomplete or distorted mental status assessment, and sometimes interpreting errors when using non-professional interpreters [34]. These pitfalls can be avoided by the use of professional TIS.

Although the different forms of translation and interpreting (e.g. telephone or video, versus in-person) seem to provide a similar level of satisfaction for users [19], our study shows that some patients would prefer to be able to add gestures to their oral explanations, so that the interpreter could get a more comprehensive overview of the situation. TIS and face-to-face interpreters seem to be complementary, as both services meet different needs among patients. One solution that combines the rapid response of the TIS with the images and non-verbal information of the presence-based situation, while simultaneously limiting costs, would be to contact the interpreters by video-conferencing [11]. Recent work by Krystallidou shows that the gaze, gestures, and orientation of the body of participants are valuable resources for interpreters to help them guide interactions between participants [35]. The TIS used in our study performed 156 interpreting services via video-conferencing compared to 330,000 telephone interpreting sessions in 2020 [36], so there is a room for increased use of the video component. In our study, the participants had a positive view of the fact that they could not be identified by the interpreter. René de Cotret and colleagues have made recommendations for developing videoconference-based remote interpreting [37]. As it is spreading, additional studies seem warranted to identify the place that video-interpreting should take in primary care for allophone migrants.

Rather than involving interpreters, Schulz et al., proposed to organize tele-consultations with doctors who speak the patient’s mother tongue [38]. However, this solution might be challenging to implement because firstly, it is unlikely that a pool of physicians could be constituted to cover all the languages represented among the migrants, and across all the medical disciplines; and secondly, the patients are located in a specific geographical area and are usually in contact with healthcare providers in that area. Delegating the follow-up of these patients to other specialists who might be several hundred kilometres away, could lead to a breakdown in the healthcare trajectory for some patients. Therefore, further development of video-conference solutions for interpreting appears to be the most attractive solution at present.

Conclusion

Our study reports the perceptions of allophone migrant patients who used telephone interpreting services during primary care in France. We found that TIS enabled improved bidirectional communication and comprehension, reinforcing patient empowerment. The interpreter facilitated the creation of a climate of trust between the doctor and the allophone patient, making it possible to reveal under-addressed reasons for consultation (such as psychological disorders). Although the immediate availability of an interpreter by telephone enables improved communication during the consultation, there may be a need to actually physically see the patient in some cases, in order to complement the oral discourse. Interpreting services using video-conferencing (image plus voice) deserve wider development, as a means to combine rapid availability of interpreting, with images and visual interaction, while simultaneously limiting costs.

Supporting information

Acknowledgments

The authors wish to thank all the patients who participated in the study, as well as all the staff and management at the CADA shelter in Bar-sur-Sein for their availability during the study.