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Signs and SymbolsDiscussion PaperDiscussionAfter the signs, symbols and communication tools were collected, it seemed appropriate to provide a review of the project and an evaluation of the resources to make some assessment of their quality. Accordingly, interviews were conducted with a small number of individuals considered to be both knowledgeable and experienced in the use of cross cultural communication tools who could review the current tools for the purpose of making recommendations for future developments in the area. Nine individuals were interviewed in total. Interviews were semi-structured and lasted between two and three hours. Specifically, the reviewers were asked to:
Distribution and sharing Distribution and sharing of resources has been a consistent theme of discussions throughout the course of the project. Reviewers felt that the resources were useful tools and that the key to their success depended on basic access issues, such as their ability to be easily located, reproduced and distributed. Some factors that appear to limit access to current resources included the following:
Solutions offered to address these specific problems included:
The quality of many of the resources came under question on a number of fronts including the quality of translation, artwork and layout. However, It became clear that the resources were also seen by some as an indication of the level of commitment of health services to providing quality care to non-English speakers. Most obviously, where resources looked unprofessional and out dated, faith in the standard and quality of service was perceived to be undermined. More importantly it was thought that the use of these tools in place of interpreters reflects that users place less value on provision of quality health services to people of culturally and linguistically diverse (CALD) backgrounds than those that would be accepted for English speakers. Cautionary Words - the limitations of communications tools Concerns were raised in relation to the use of many of the tools collected. In particular, concerns were raised regarding the potential for the use of communication tools by health care workers and their clients to be seen as a substitute for interpreters by some health care workers. While it was acknowledged that in certain circumstances interpreters are not available or not required, it was felt that all of the resources should clearly indicate to both health care worker and client alike that an interpreter will be made available to them if required. Some of the commentary went further to suggest that communication tools such as these should only ever be used after a formal language assessment had been conducted. The potential for miscommunication was also raised, cautioning that the individual tools (without parallel use of Health Care Interpreters) offer limited information or options and often only allow one-way communication. Communication tools that attempt to facilitate a diagnosis or assessment were felt to be seriously limited (or even potentially dangerous) due to their lack of feedback and clarification. The potential for miscommunication to cause problems, small and large, meant that communication tools were considered to be inefficient or inappropriate in diagnostic and assessment situations. The commentary also stresses the importance of duty of care; the intention of signs, symbols and communication tools is to facilitate understanding. A number of respondents raised the possibility that individuals and facilities could be mistakenly led to believe that the sign or symbol alone fulfilled their duty of care to non-English speaking clients. They cautioned that it is the responsibility of health staff to ensure that information is received and understood, not just made available. External Factors In addition to their intrinsic limitations, the communication value of signs, symbols and communication tools can also be influenced by external factors that are beyond the immediate control of health care workers and the clients who rely on them. In no particular order these included factors related to:
There were a number of suggestions about how the tools could be improved by making simple changes in design and layout. These included: using more white space in written documents, using bright colours that attract attention, using lower case rather than upper case, choosing large clear fonts as well as changing fonts for each different language. Generally reviewers felt that the tools could benefit from the use of professional designers (sensitive to cross-cultural issues) to ensure that the layout is clear and easy to follow and identical designs are used for both the English and all other language versions. Importantly reviewers felt strongly that the designs should reflect the importance of the information being communicated; many of the signs gave warning signals that exaggerated their importance while others that were potentially very important were diminutive in style. Equally it seemed important to maintain the balance between providing as many options as possible while remaining clear, concise and functional. Information should be prioritised and grouped according to a logic that is clear to the reader and not just the author. Reviewers were keen to point out the need to explore new technology; that translated text was not the only option. Of particular interest was the use of computer-generated information and the use of pre-recorded messages played over facility intercoms in community languages. Translation Issues Assessing the quality of translation in the signs, symbols and communication tools was difficult, particularly in view of the fact that (with the exception of one) no developmental information was available for any of the resources. Generally, the reviewers who were fluent in other languages quickly and easily found errors in translated words, incorrect grammar, language styles and reading ages or pitch that were considered inappropriate for the intended audience and context. The reviewers emphasised that translation of signs, symbols and communication tools should be undertaken by qualified, professional translators. Like their English counterparts, translated health and medical material should be subject to a technical review by qualified (bilingual) health professionals with expertise in the topic area and be appropriately field tested to ensure the language style and pitch is suited to the intended audience. In the absence of a style guide for translations, the reviewers suggested that when appropriate all translated material, including signage, be clearly labeled with the date and the language of the translation and that all titles and headings be translated in English. It was felt that this would help to ensure that the tools are current, appropriate and consistent. Communication Issues The most salient point to emerge from the reviewers was that we need to "get it right" in English before we can hope to communicate across cultures. By this they meant simply that writers should:
The use of pictograms and symbols was seen as an efficient way of communicating directions and simple health and medical facility information. However, it is necessary to be clear about the limitations of this kind of visual communication, for example, people with some cognitive impairment or low literacy levels may be unable to interpret stylised, two-dimensional diagrams. It was also acknowledged that while the symbols and pictograms needed to be simple and stylised to make sense, they sometimes went too far and became obscure and unhelpful. Clearly, complex information can't be accurately communicated using pictures alone and requires the presence of a Health Care Interpreter and the support of other forms of communication to be fully comprehended. Important questions were raised about whether pictures and symbols in communication are universally understood; "standard symbols" don't always have one universal meaning as implied nor do stylised pictures have the same meaning across cultures. Clothing and food pictures are obvious examples where commonality may not exist across cultures. Other noteworthy observations on communication generally include the following:
A number of recommendations and suggestions were made during the course of the project. In addition, the individuals who were asked to comment on the material were also specifically asked to make recommendations for the development of signs, symbols and communication tools for health settings. The recommendations and suggestions were as follows:
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