About the Author(s)

Talat Habib Email symbol
Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Family Medicine, Robert Mangaliso Sobukwe Hospital, Kimberley, South Africa

Arun Nair symbol
Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Family Medicine, Robert Mangaliso Sobukwe Hospital, Kimberley, South Africa

Klaus von Pressentin symbol
Division of Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Ramprakash Kaswa symbol
Department of Family Medicine and Rural Health, Walter Sisulu University, Mthatha, South Africa

Mthatha General Hospital, Mthatha, South Africa

Hamid Saeed symbol
Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Department of Family Medicine, Robert Mangaliso Sobukwe Hospital, Kimberley, South Africa


Habib T, Nair A, Von Pressentin K, Kaswa R, Saeed H. Do not lose your patient in translation: Using interpreters effectively in primary care. S Afr Fam Pract. 2023;65(1), a5655. https://doi.org/10.4102/safp.v65i1.5655

CPD Article

Do not lose your patient in translation: Using interpreters effectively in primary care

Talat Habib, Arun Nair, Klaus von Pressentin, Ramprakash Kaswa, Hamid Saeed

Received: 25 Oct. 2022; Accepted: 23 Jan. 2023; Published: 27 Feb. 2023

Copyright: © 2023. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


South Africa is a multicultural society characterised by a rich diversity of languages. As a result, many healthcare providers and their patients often do not speak the same language, which makes communication challenging. The language barriers, when present, require an interpreter to ensure accurate and effective communication between the parties. In addition to assisting in a clear exchange of information, a trained medical interpreter also acts as a cultural liaison. This is especially true when the provider and the patient come from different cultural backgrounds. Based on the patient’s needs, preferences, and available resources, clinicians should select and engage with the most appropriate interpreter. The effective use of an interpreter requires knowledge and skill. Patients and healthcare providers can benefit from several specific behaviours during interpreter-mediated consultations. This review article provides practical tips on when and how to use an interpreter effectively during clinical encounters in primary healthcare settings in South Africa.

Keywords: medical interpreter; modes of interpretation; types of medical interpreters; cultural liaison; communication barriers; primary care.


With over 50 established and unestablished languages in South Africa,1 it is unusual for healthcare providers and patients to share the same first language during most clinical encounters.2 Language thus becomes a significant barrier to clear communication between the parties, necessitating the use of an interpreter.3 It is a reality that South Africa is a popular destination for cross-border African migrants seeking employment or asylum abroad.4 These immigrants often face cultural and linguistic barriers within the healthcare system that prevent them from receiving quality care.4 There is growing evidence, locally and globally, that poor communication due to language barriers poses a significant health threat.5,6,7,8,9,10 South African legislation recognises the importance of language in healthcare communication and the right of all citizens to receive healthcare and information in a language they are familiar with. This is reflected both in the Constitution and in the National Health Act (Act 61 of 2003).11,12 Yet, interpreters are not mentioned in the National Department of Health’s 2030 Human Resources for Health (HRH) Strategy.13 Thus, the country has a shortage of health and medical administrative services (Table 13 in the 2030 HRH strategy).13

Translation and interpretation are related, yet different skills. While translators deal with converting written text from one language to another, interpreters work with spoken words in live situations like a clinical consultation.14 However, interpretation in healthcare involves much more than simply having a bilingual person assist in communication between the patient and the provider.15 Trained interpreters improve healthcare quality, clinical outcomes and patient satisfaction.15,16,17 To provide holistic and individualised care mandated by the World Health Organization,18 clinicians must possess essential knowledge and skills to use interpreters effectively in primary health care.10,15

Local studies highlight the negative impact of language barriers on the quality and access to healthcare services and the need for trained interpreters in the South African healthcare context.5,6,10,19 In the absence of trained interpreters, primary care providers rely on untrained bi- or multilingual staff, family members, or friends, which presents serious ethical and medical challenges. Ad hoc interpreters in local studies were found to have inadequate language proficiency and were prone to frequent errors during interpretation.5,19,20 Most published data on this topic comes from the Western Cape Province and isiXhosa-speaking patients.5 Thus, a research gap exists regarding other provinces and languages in South Africa. This review article aims to provide clinicians with practical tips on engaging with patients more meaningfully by using interpreters effectively during a consultation. Thus, it will assist in reducing language and cultural barriers within the primary healthcare system in South Africa.

What is the role of a medical interpreter?

The International Association of Medical Interpreters defines interpretation as:

[T]he conversion of a message uttered in a source language into an equivalent message in the target language so that the intended recipient of the message responds to it as if he or she had heard it in the original.21

Language is not just a means of expressing our thoughts and ideas; it also carries cultural values, attitudes and identity. As such, an interpreter acts beyond a mere language conduit, becoming a cultural liaison between the patient and the provider.16 The Code of Ethics of trained interpreters promotes confidentiality, professionalism and client trust.22 Medical interpreters typically use sequential or consecutive interpretation, meaning they speak after the original speaker has finished speaking in the source language.16

When do you need an interpreter?

When a patient and the provider are not proficient in the same language, there is a risk of miscommunication. You must consider the need for interpretation if your patient responds to your questions with a nod or a simple ‘yes’ or ‘no’. An open-ended question that cannot be answered by ‘yes’ or ‘no’ can help determine their proficiency level with the language used. Also, ask them to repeat what you have just said in their own words. This simple test can reasonably indicate whether an interpreter is required.23

It is also important to know your own limitations in a particular language. In the authors’ experience, with limited language ability, it is easy to ask questions but difficult to fully understand the patient’s response.

What are the types of medical interpreters?

  • Professional or trained interpreters: There is good evidence that a professionally trained interpreter not only improves clinical outcomes and patient satisfaction but also reduces communication errors, unnecessary investigations, hospital stay, readmission rate and malpractice risk.17,24,25,26 Their training in language, basic knowledge of medical terminology and diseases, cultural proficiency and professional ethics make them the gold standard. According to the authors’ personal communication with provincial Human Resources officials, except for a few select facilities, most healthcare settings in South Africa lack trained interpreters.
  • Informal or ad hoc interpreters: In the absence of trained interpreters, family members, friends and neighbours accompanying the patient serve as interpreters. They pose serious challenges related to confidentiality, impartiality, increased errors in interpretation, and may distort the message due to cultural reasons or personal agendas.14,15,16,17,26,27 It is important to note that minor children should not be used as interpreters except in emergencies (Box 1).15,17,29 Even in unavoidable situations, their use demands careful consideration based on the context of information that needs to be exchanged. There is a difference between using a 10-year-old son to take a menstrual history from his mother and a 16-year-old daughter to enquire about her father’s diabetic medication. Legislations in some countries explicitly ban the use of minor children for interpretation in non-emergency situations.29,30
  • Bi- or multilingual healthcare staff: It includes doctors, nurses, and other staff in healthcare facilities. When trained and appropriately used, they become valuable assets for effective communication. However, errors are more likely to occur because they are often untrained and not formally assessed in their language abilities.14,16 It is common practice in the South African healthcare sector to use untrained bi- or multilingual staff and ad hoc interpreters.20 Despite not being the first choice, ad hoc interpreters (e.g. family or friends) have some benefits and may often be the only option available in the facility (Table 1).
BOX 1: Risks of using children as medical interpreters.
TABLE 1: Potential benefits and risks of using untrained family and/or friends for healthcare interpretation.

What are the modes of interpretation?

These depend on the available resources, for example, in-person, telephonic, video remote interpretation or web-based applications.24

  • In-person face-to-face: The interpreter is physically present with the provider and the patient. It is the preferred choice when available.14,29 It enables the user to observe non-verbal language, behaviour and personal characteristics, enhancing communication.
  • Telephonic: Patients and providers are linked to the trained interpreter via an audio device. It can be a cost-effective solution for remote areas and languages which are less commonly spoken. The patient may remain more anonymous and comfortable, especially when discussing sensitive issues.15,16 However, certain limitations, such as loss of body language and a lack of continuity, should be recognised.5,15,16 Some developed countries, such as Australia, provide free national telephone interpretation services to their clinicians.31 There are few private for-profit companies in South Africa offering professional telephonic interpreter services for a fee.
  • Video remote interpretation: The use of smart devices and applications to access professional interpretation services is on the rise. With this technology, advanced features, such as spoken words appearing as text on screen, provide an advantage when communicating with a hearing-impaired patient without an in-person sign language interpreter.15,17
  • Web-based translation applications: New applications that enable voice-to-voice and voice-to-text communications are improving. While these applications may be useful in simple, low-risk healthcare encounters, their role in complex healthcare settings has yet to be determined because of multiple patient safety concerns.28,32,33

Medicolegal considerations of working across language and cultural barriers in primary care

If an interpreter is necessary, primary care providers should be aware of the medicolegal risks and implications of not engaging one. It may be crucial in certain situations, such as obtaining a patient’s consent for a procedure or assessing their ability to make decisions.

In its ethical guidance for good practice, the Health Professions Council of South Africa (HPCSA) recommends using an interpreter if a linguistic or cultural barrier prevents effective communication. For instance, HPCSA provides the following recommendation in its guidelines for withholding and withdrawing treatment (booklet 7, p. 4, section 7.1.7):

A linguistic or cultural barrier may exist between health care practitioners and the patient. Under these circumstances, an interpreter fluent in the language used by the patient should be present in order to facilitate communication when discussions are held and decisions regarding the treatment of the patient are to be made.34

It is important to understand the potential risks associated with ad hoc interpreters when clinical decisions are complex and critical (Table 1).

  • The use of interpreters should be documented. Patients’ clinical and/or medicolegal records should be updated as per HPCSA guidelines (booklet 9).34

Currently, there is no explicit policy in the HPCSA guidelines requiring patients to provide written consent if they wish to use language interpretation services.

How to work effectively and efficiently with medical interpreters?15,16,17,23,35

Before the consultation
  • Choose an appropriate interpreter and the mode of interpretation based on specific needs, available resources and patient preference.
  • Meet the interpreter to build rapport and share the patient’s background information and expectations during the interview (Box 2)36,37,38.
  • Schedule the interview for a suitable time and location, allowing extra time.
  • Ensure that the equipment for the interview has been tested and is in working order when considering an alternative to in-person interpretation.
BOX 2: Key points on the cultural liaison aspect of interpretation.
During the consultation
  • Introduce and/or identify everyone present during the interview.
  • Provide a comfortable environment conducive to the free exchange of information.
  • Position the interpreter next to or slightly behind the patient in an ambulatory setting.
  • The interpreter and provider should stand side-by-side in a casualty or inpatient setting so the patient can easily see both.
  • Be interested and maintain regular eye contact.
  • Speak directly to the patient in the first person, using ‘I’ and ‘you’ statements. Do not address the patient indirectly via an interpreter in third-person language, for example, ‘ask him’ or ‘tell her’.
  • Speak clearly and slowly, using simple common words and short sentences.
  • Limit the number of key points to a minimum and ask one question at a time.
  • Avoid slang, complex medical jargon, acronyms and idioms.
  • Avoid humour and jokes; they may be difficult to understand or inappropriate in another language or culture.
  • Insist on sentence-by-sentence interpretation. The interpreter must not answer for the patient.
  • Allow the interpreter sufficient time to answer your question.
  • While waiting silently for the patient’s response, use this so-called ‘negative space’ effectively by observing the patient’s non-verbal clues and formulating your next question.
  • Stay in command of the interview process. If much side talk takes place, you may interrupt the conversation and regain control.
  • Check and reinforce the patient’s understanding by techniques such as ‘teach-back’ or ‘show me’.
  • Provide closure at the end of the interview by summarising key information.
After the consultation
  • Thank the interpreter.
  • Discuss and clarify medical, social, cultural, or ethical concerns.
  • Offer debriefings after emotionally taxing interviews.
  • Plan follow-up appointments and referrals to the primary care team members or other levels of care if indicated.
  • The use of an interpreter should be documented in the patient’s clinical notes and/or medicolegal records.


Medical interpreters are an important and relevant staffing category within primary healthcare. Their role and value in healthcare teams should be recognised within national HRH policy to address the current gap. This will ensure that primary care teams comprise appropriate human resources and skill sets.

Because of the risks associated with ad hoc interpreter use, there is an urgent need to establish easily accessible trained interpreter services in the primary health care sector in South Africa. The availability of trained interpreters can be further supported by a centralised telephone interpreter service.

Education modules on the use of interpreters may be incorporated into undergraduate, postgraduate or registrar training and continuing medical education programmes. Courses designed to enhance communication skills and use interpreters effectively should be offered to primary care providers. Additionally, language courses might be offered at the undergraduate and graduate levels of health professions education.

Bi- or multilingual medical staff, with adequate training and support, can serve as valuable backup resources.


Patients with limited proficiency in the provider’s language need interpreters. Effective use of interpreters requires knowledge and skill sets. Interpreters are valuable communication aids and cross-cultural guides in healthcare. Type and mode of interpretation depend on the need of the patient, availability of resources and patient preference. A trained and professional interpreter is the gold standard. Informal ad hoc interpreters should be used with caution.

Minor children should not be used as interpreters except in an emergency. During the consultation, speak directly to the patient using first-person language. Insist on sentence-by-sentence interpretation, observe non-verbal clues and stay in control of the process. Be sensitive to cultural differences.


Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

T.H. conceptualised the idea and wrote the first draft. A.N., K.v.P., R.K. and H.S. contributed to the manuscript’s critical evaluation and approved the final draft.

Ethical considerations

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

Data sharing does not apply to this article as no new data were created or analysed in this study.


The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.


  1. Eberhard DM, Simons GF, Fennig CD. Ethnologue: Languages of South Africa [homepage on the Internet]. 25th ed. 2022 [cited 2022 Oct 09]; p. 1–52. Available from: http://www.ethnologue.com
  2. Levin M. Language as a barrier to care for Xhosa-speaking patients at a South African paediatric teaching hospital. S Afr Med J [serial online]. 2006 May 12 [cited 2022 Oct 10];96(10):1076–1079. Available from: https://www.ajol.info/index.php/samj/article/view/135523
  3. Benjamin E, Swartz L, Hering L, Chiliza B. Language barriers in health: Lessons from the experiences of trained interpreters working in public sector hospitals in the Western Cape. In: Padarath A, King J, Mackie E, Casciola J, editors. South African health review 2016. Durban: Health Systems Tr. South African Health Review, 2016; p. 73–81.
  4. Hunter-Adams J, Rother HA. A qualitative study of language barriers between South African health care providers and cross-border migrants. BMC Health Serv Res. 2017;17(1):97. https://doi.org/10.1186/s12913-017-2042-5
  5. Van Den Berg VL. Still lost in translation: Language barriers in South African health care remain. S Afr Fam Pract. 2016;58(6):229–231. https://doi.org/10.1080/20786190.2016.1223795
  6. Deumert A. ‘It would be nice if they could give us more language’ – Serving South Africa’s multilingual patient base. Soc Sci Med. 2010;71(1):53–61. https://doi.org/10.1016/j.socscimed.2010.03.036
  7. Benda NC, Wesley DB, Nare M, Fong A, Ratwani RM, Kellogg KM. Social determinants of health and patient safety: An analysis of patient safety event reports related to limited English-proficient patients. J Patient Saf. 2022;18(1):e1–e9. https://doi.org/10.1097/PTS.0000000000000663
  8. Floyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: Layers of disadvantage. Int J Equity Health. 2017;16(1):195. https://doi.org/10.1186/s12939-017-0694-8
  9. De Moissac D, Bowen S. Impact of language barriers on quality of care and patient safety for official language minority francophones in Canada. J Patient Exp. 2018 Apr 18;6(1):24–32. https://doi.org/10.1177/2374373518769008
  10. Schlemmer A, Mash B. The effects of a language barrier in a South African district hospital. S Afr Med J [serial online]. 2006 [cited 2022 Oct 09];96(10):1084–1087. Available from: http://www.samj.org.za/index.php/samj/article/view/1311
  11. The Constitution of The Republic of South Africa [homepage on the Internet]. [cited 2022 Oct 09]. Available from: https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf
  12. Government Gazette Republic of South Africa [homepage on the Internet]. 2004 [cited 2022 Oct 09]. Available from: https://www.gov.za/sites/default/files/gcis_document/201409/a61-03.pdf
  13. 2030 Human resources for health strategy: Investing in the health workforce for universal health coverage [homepage on the Internet]. 2020 [cited 2022 Oct 12]. Available from: https://www.spotlightnsp.co.za/wp-content/uploads/2020/08/2030-HRH-strategy-19-3-2020.pdf
  14. Torres B. Best practice recommendations for hospital-based interpreter services office of minority health [homepage on the Internet]. [cited 2022 Oct 09]. Available from: https://www.imiaweb.org/uploads/pages/463_2.pdf
  15. Kasten MJ, Berman AC, Ebright AB, Mitchell JD, Quirindongo-Cedeno O. Interpreters in health care: A concise review for clinicians. Am J Med. 2020;133(4):424–428.e2. https://doi.org/10.1016/j.amjmed.2019.12.008
  16. Hadziabdic E, Hjelm K. Working with interpreters: Practical advice for use of an interpreter in healthcare. Int J Evid Based Healthc. 2013;11(1):69–76. https://doi.org/10.1111/1744-1609.12005
  17. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476–480.
  18. United Nations Human Rights, World Health Organization. Human rights, health and poverty reduction strategies [homepage on the Internet]. Health and Human Rights Publications Series. 2008 [cited 2022 Oct 12]. Available from: https://www.ohchr.org/sites/default/files/Documents/Publications/HHR_PovertyReductionsStrategies_WHO_EN.pdf
  19. Hagan S, Swartz L, Kilian S, Chiliza B, Bisogno P, Joska J. The accuracy of interpreting key psychiatric terms by ad hoc interpreters at a South African Psychiatric Hospital. Afr J Psychiatry (South Africa). 2013;16(6):424–429. https://doi.org/10.4314/ajpsy.v16i6.54
  20. Hagan S, Hunt X, Kilian S, Chiliza B, Swartz L. Ad hoc interpreters in South African psychiatric services: Service provider perspectives. Glob Health Action. 2020;13(1):1684072. https://doi.org/10.1080/16549716.2019.1684072
  21. International Medical Interpreters Association (IMIA) [homepage on the Internet]. [cited 2022 Oct 11]. Available from: https://www.imiaweb.org/about/faqs.asp
  22. Hernandez-iverson BE. IMIA guide on medical interpreter ethical conduct: ‘The code of ethics represents a baseline and an assurance to clients, patients and interpreters’. 2010; p. 1–11.
  23. Gray B, Hilder J, Stubbe M. How to use interpreters in general practice: The development of a New Zealand toolkit. J Prim Health Care. 2012;4(1):52–61. https://doi.org/10.1071/HC12052
  24. Jacobs B, Ryan AM, Henrichs KS, Weiss BD. Medical interpreters in outpatient practice. Ann Fam Med. 2018;16(1):70–76. https://doi.org/10.1370/afm.2154
  25. Huang YT, Phillips C. Telephone interpreters in general practice. Aust Fam Physician [serial online]. 2009 [cited 2022 Oct 11];38(6):443–446. Available from: https://www.racgp.org.au/afp/2009/june/telephone-interpreters
  26. Atkin N. Getting the message across: Professional interpreters in general practice. Aust Fam Physician. 2008;37(3):174–176.
  27. Rimmer A. Can patients use family members as non-professional interpreters in consultations? BMJ. 2020;368:m447. https://doi.org/10.1136/bmj.m447
  28. Migrant and Refugee Women’s Health Partnership. Guide for clinicians working with interpreters in healthcare settings [homepage on the Internet]. 2019 [cited 2022 Oct 11]. Available from: https://ausit.org/wp-content/uploads/2020/02/Guide-for-clinicians-working-with-interpreters-in-healthcare-settings-Jan2019-1.pdf
  29. Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60(5):545–553. https://doi.org/10.1016/j.annemergmed.2012.01.025
  30. New 2016 ACA rules significantly affect the law of language access | critical measures, LLC [homepage on the Internet]. [cited 2022 Oct 09]. Available from: https://cmelearning.com/new-2016-aca-rules-significantly-affect-the-law-of-language-access/
  31. Bird S. Failure to use an interpreter. Aust Fam Physician. 2010;39(4):241–242.
  32. Panayiotou A, Gardner A, Williams S, et al. Language translation apps in health care settings: Expert opinion. JMIR Mhealth Uhealth. 2019;7(4):e11316. https://doi.org/10.2196/11316
  33. Vieira LN, O’Hagan M, O’Sullivan C. Understanding the societal impacts of machine translation: A critical review of the literature on medical and legal use cases. Inf Commun Soc. 2021;24(11):1515–1532. https://doi.org/10.1080/1369118X.2020.1776370
  34. Protecting the public and guiding the professions ethical guidelines for good practice in the health care professions [homepage on the Internet]. [cited 2022 Oct 12]. Available from: https://www.hpcsa.co.za/Uploads/Professional_Practice/Ethics_Booklet.pdf
  35. Phillips C. Using interpreters – A guide for GPs. Aust Fam Physician [serial online]. 2010 Apr;39(4):188–195. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20372676
  36. Dysart-Gale D. Clinicians and medical interpreters: Negotiating culturally appropriate care for patients with limited English ability. Fam Community Health. 2007;30(3):237–246. https://doi.org/10.1097/01.fch.0000277766.62408.96
  37. Brooks LA, Manias E, Bloomer MJ. Culturally sensitive communication in healthcare: A concept analysis. Collegian. 2019;26(3):383–391. https://doi.org/10.1016/j.colegn.2018.09.007
  38. Maier-Lorentz MM. Transcultural nursing: Its importance in nursing practice. J Cult Divers [serial online]. 2008 [cited 2022 Oct 11];15(1):37–43. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-61949128224&partnerID=40&md5=e7917f461bf02b1cf6fa6bec8733a449

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