The Landscape of Direct-To-Consumer Genetic Testing in Reproductive Health Contexts: An Analytical Framework of Stakeholders and Their Competing Motivations.

We propose a theoretical framework that identifies (a) the different categories of stakeholders and (b) the normative values that drive their attitudes toward direct-to-consumer genetic testing, with an emphasis on the reproductive health contexts. We conducted a literature search using varied combinations of search terms, including direct-to-consumer genetic testing, decision-making, reproductive health, and policy. Using a grounded theory approach to existing literature and in combination with a narrative review, we present a systematic framework of five categories of stakeholders (i.e., genome-driven stakeholders, industry-driven stakeholders, history-driven stakeholders, value-driven stakeholders, and social justice-driven stakeholders) that shape the public's discourse. Moving beyond the dialectical ethics that have governed the public discourse, we also identify the normative values and interests that motivate different stakeholders' attitudes and decision-making through theoretical sampling under the grounded theory. We investigate the competing and conflicting values within the same category of stakeholders. For example, despite being industry-driven stakeholders, medical professionals' attitudes are driven by concerns about standards of care; in contrast, health insurance companies' concerns are centered on profit. We further explore the tensions between these stakeholders that impact their strategic alliances and pose challenges to the practices of direct-to-consumer genetic testing. Finally, we examine how these stakeholders and their corresponding values may shape future development and policies of direct-to-consumer genetic testing in the context of reproductive health.

Doctors, Patients, and Interpreters' Views on the Co-Construction of Empathic Communication in Interpreter-Mediated Consultations: A Qualitative Content Analysis of Video Stimulated Recall Interviews.

Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters' communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters' perspectives on their own and others' actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters' alterations or disengaged demeanor. Some aspects of doctors and interpreters' professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants' communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.

Integrative Nutritional Counseling Combining Chinese Medicine and Biomedicine for Chinese Americans with Type 2 Diabetes: A Mixed-Methods Feasibility Study.

Objectives: This study describes the development and feasibility of Integrative Nutritional Counseling (INC), a Chinese medicine (CM)+biomedicine-based nutrition curriculum for Chinese Americans with type 2 diabetes. Although Chinese Americans often incorporate CM principles into their diet, scant research has explored how to integrate CM with biomedical nutrition standards in a culturally appropriate manner or if such a program could improve diabetes self-management. Design: This is a 1-month pre-post study design including three points of contact: baseline, in-person class, and 1-month follow-up. Subjects: Participants (n = 15) were Cantonese-speaking/reading Chinese Americans diagnosed with type 2 diabetes who had used some form of CM/medicinal foods in the last 12 months. Interventions and Outcome Measures: The INC program included baseline surveys and a CM intake interview conducted by a licensed acupuncturist. The acupuncturist generated a CM diagnosis, which was shared with the participant, and used this diagnosis to tailor brief nutrition education. To bolster this brief education, a bilingual registered dietitian provided a 2-h group education class in Cantonese to all participants, during which time participants also received a Chinese/English INC booklet. Participants completed surveys immediately after the class and at 1-month follow-up, with qualitative exit interviews. Results: Participants reported improved attitudes and dietary habits aligning directly with INC, and improvement in biomedically valued measures of type 2 diabetes, such as weight loss, and CM-valued measures of digestion/elimination and hot/cold feeling. Satisfaction with INC was high, but challenges included confusion with some INC information, structural barriers, and comorbidities. Conclusions: Chinese Americans with type 2 diabetes and interventionists found integrative nutrition approaches acceptable and feasible. Future research should examine INC with a larger population and explore optimal delivery of INC given reported challenges.

Rethinking Interpreter Functions in Mental Health Services.

Interpreters improve access to care for patients with limited English proficiency (LEP), but some studies have reported poorer cultural understanding, relationship quality, and patient satisfaction than with language-concordant care. Use of interpreter roles beyond linguistic conversion (clarifier, cultural broker, or advocate/mediator) may enhance interpreter-mediated care by improving cultural understanding and the therapeutic alliance. As reported in this column, pilot data on interpreter-mediated evaluations of 25 psychiatric outpatients with LEP support this position. The authors found that clarification of the interpreter's role and the session structure improved provider-interpreter collaboration, with two perceived benefits: improved assessment through elicitation of clinically relevant information and stronger therapeutic alliance through "emotion work." Strategies for effectively enhancing provider-interpreter collaboration are discussed.

Reconceptulizing Language Discordance: Meanings and Experiences of Language Barriers in the U.S. and Taiwan.

Individuals with language barriers may face challenges unique to a host society. By examining and comparing the sociocultural conditions that can result in providers and patients not sharing the same language in the United States and in Taiwan, I argue that (a) language discordance is a social phenomenon that may entail diverging meanings and experiences in different countries; (b) language-discordant patients may not share similar experiences even if they are in the same country; and (c) disparities in language concordance may be confounded with other disparities and cultural particulars that are unique to a host society. In addition, because English is a dominant language in medicine, language-discordant patients' quality of care in Taiwan can be moderated by their fluency in English.

Surviving Violence in Everyday Life: A Communicative Approach to Homelessness.

In this narrative review, the author synthesizes the literature on homelessness across various disciplines (e.g., public health, social work, sociology, and communication) to demonstrate how the experiences of homelessness can be created, maintained, and reinforced through communication, including interpersonal interactions and public discourse. By conceptualizing homelessness as a culturally constructed and socially situated phenomenon, the author examines (a) the complex conceptualization of homelessness, (b) everyday violence faced by people who are homeless, and (c) coping strategies of people who are homeless. In summary, homelessness is a complex social phenomenon, involving tensions between individuals, families, and social systems, all of which are situated in the larger sociocultural and sociopolitical contexts of a specific time and place.

"Not Homeless Yet. I'm Kind of Couch Surfing": Finding Identities for People at a Homeless Shelter.

The meanings of homelessness are fluid and socially constructed, providing resources and limitations for individuals to negotiate their identities and relationships in everyday life. In this study, we examine the strategies and corresponding resources utilized by people who are homeless to cope with the labeling of a homeless identity and to redefine their identities. We used constant comparative analysis to examine in-depth interviews with 16 participants (male = 11, female = 5) who access a local homeless shelter in the southwest United States for resources. We identified three strategies that homeless people adopt to cope with the labeling of homeless identity: (a) differentiating oneself from others who are homeless, (b) prioritizing certain aspects of life, and (c) embracing the status of homelessness. Although these strategies have been identified in previous literature, the authors extend this line of research by identifying the common resources people who are homeless utilize when adopting these strategies, which entail important implications for theory development and practical implications.

Voices of the Homeless: An Emic Approach to the Experiences of Health Disparities Faced by People Who Are Homeless.

People who are homeless are particularly vulnerable to health disparities. Rather than using population statistics to highlight the prevalence or severity of the suffering of people who are homeless, 28 undergraduate students each conducted an in-depth interview with an individual who relied on a local homeless shelter to cope with everyday life. The interview explored the participants' health concerns and strategies for health management. Due to equipment failure and incomplete recording, only 16 interviews are included in this study. The author adopted thematic analysis while focused on preserving the richness of the interactions between the participants who are homeless and the undergraduate students. The author's goal is to provide emic, intimate insights about the struggles and challenges faced by the people who are homeless. The author concluded the study by situating the findings in the larger literature of health disparities experienced by people who are homeless.

"It's Not Like You Need to Live 10 or 20 Years": Challenges to Patient-Centered Care in Gynecologic Oncologist-Patient Interactions.

The literature suggests that the patient-perspective approach (i.e., eliciting and responding to patients' perspectives, including beliefs, preferences, values, and attitudes) to patient-centered care (PCC) is not a reliable predictor of positive outcomes; however, little is known about why the patient-perspective approach does not necessarily lead to positive outcomes. By using discourse analysis to examine 44 segments of oncologist-patient interactions, we found that providers' use of patient-perspective contextualization can affect the quality of care through (a) constructing the meanings of patient conditions, (b) controlling interpreting frames for patient conditions, and (c) manipulating patient preferences through strategic information sharing. We concluded that providers' use of patient-perspective contextualization is an insufficient indicator of PCC because these discursive strategies can be used to control and manipulate patient preferences and perspectives. At times, providers' patient-perspective contextualization can silence patients' voice and appear discriminatory.

Conceptualizing emotion in healthcare interpreting: A normative approach to interpreters' emotion work.

OBJECTIVES: By juxtaposing literature in signed language interpreting with that of spoken language interpreting, we provide a narrative review to explore the complexity of emotion management in interpreter-mediated medical encounters. METHODS: We conduct literature search through library databases and Google Scholar using varied combinations of search terms, including interpreter, emotion, culture, and health care. RESULTS: We first examine (a) interpreters' management and performance of others' emotions, (b) interpreters' management and performance of their own emotions, and (c) impacts of emotion work for healthcare interpreters. CONCLUSION: By problematizing the roles and functions of emotion and emotion work in interpreter-mediated medical encounters, we propose a normative model to guide future research and practices of interpreters' emotion management in cross-cultural care. PRACTICE IMPLICATIONS: Quality and equality of care should serve as the guiding principle for interpreters' decision-making about their emotions and emotion work. Rather than adopting a predetermined practice, interpreters should evaluate and prioritize the various clinical, interpersonal, and therapeutic objectives as they consider the best practice in managing their own and other speakers' emotions.

Health as Submission and Social Responsibilities: Embodied Experiences of Javanese Women With Type II Diabetes.

By examining women's experiences with type II diabetes, we explore how illness can provide resources to construct meanings of everyday life in Javanese culture. We conducted in-depth interviews with 30 female participants in Central Java, Indonesia, and adopted grounded theory for data analysis. We identified four themes that diabetes serves as resources for women in Indonesia to (a) normalize suffering, (b) resist social control, (c) accept fate, and (d) validate faith. We concluded by noting three unique aspects of Javanese women's illness management. First, through the performance of submission, our participants demonstrated spirituality and religiosity as essential elements of health. Second, diabetes empowers individuals in everyday suffering through two divergent processes: embracing submission and resisting control. Finally, diabetes provides opportunities for individuals within a social network to (re)negotiate social responsibilities. In summary, diabetes provides unique resources to empower our participants to obtain voices that they otherwise would not have had.

Not just "getting by": factors influencing providers' choice of interpreters.

BACKGROUND: Providers consistently underutilize professional interpreters in healthcare settings even when they perceive benefits to using professional interpreters and when professional interpreters are readily available. Little is known about providers' decision-making processes that shape their use of interpreters. OBJECTIVE: To understand the variety of considerations and parameters that influence providers' decisions regarding interpreters. DESIGN: A qualitative, semi-structured interview guide was used to explore providers' decision making about interpreter use. The author conducted 8 specialty-specific focus groups and 14 individual interviews, each lasting 60-90 minutes. PARTICIPANTS: Thirty-nine healthcare professionals were recruited from five specialties (i.e., nursing, mental health, emergency medicine, oncology, and obstetrics-gynecology) in a large academic medical center characterized as having "excellent" interpreter services. APPROACH: Audio-recorded interviews and focus groups were transcribed and analyzed using grounded theory to develop a theoretical framework for providers' decision-making processes. KEY RESULTS: Four factors influence providers' choice of interpreters: (a) time constraints, (b) alliances of care, (c) therapeutic objectives, and (d) organizational-level considerations. The findings highlight (a) providers' calculated use of interpreters and interpreting modalities, (b) the complexity of the functions and impacts of time in providers' decision-making process, and (c) the importance of organizational structures and support for appropriate and effective interpreter utilization. CONCLUSIONS: Providers actively engage in calculated use of professional interpreters, employing specific factors in their decision-making processes. Providers' understanding of time is complex and multidimensional, including concerns about disruptions to their schedules, overburdening others' workloads, and clinical urgency of patient condition, among others. When providers make specific choices due to time pressure, they are influenced by interpersonal, organizational, therapeutic, and ethical considerations. Organizational resources and guidelines need to be consistent with institutional policies and professional norms; otherwise, providers risk making flawed assessments about the effective and appropriate use of interpreters in bilingual health care.

Bilingual health communication: distinctive needs of providers from five specialties.

Understanding providers' expectations and needs for medical interpreters can provide important insight into the dynamics and process of interpreter-mediated medical encounters. This is one of the first mixed-methods studies on the similarities and differences of providers' views of interpreters across five specialties (i.e., obstetrics/gynecology, emergency medicine, oncology, mental health, and nursing). The two-stage studies include interview data with 39 providers and survey data with 293 providers. We used principal component analysis to identify three components in the survey data that represent providers' views of interpreters: Patient Ally, Health Care Professionals, and Provider Proxy. We then used the interview data as exemplars to illuminate the quantitative findings. Patient Ally was the only component that reached significant differences between different specialties. Providers from different specialty areas differ significantly in their expectations on interpreters' ability (a) to assist patients outside of medical encounters and (b) to advocate for the patient. In particular, nursing professionals place more importance on these two abilities than mental health providers and oncologists. Based on our findings, we proposed three research directions necessary to advance the field of bilingual health communication: to reevaluate and reconceptualize interpreters' appropriate performances with special attention to the Patient Ally dimension, to examine the commonly held attitudes for all providers and the potential tensions within these attitudes, and to identify contextual factors that influence participants' perceptions, evaluations, and choices of interpreters and their corresponding impacts.

Medical interpreters as tools: dangers and challenges in the utilitarian approach to interpreters' roles and functions.

OBJECTIVE: This study explores the tensions, challenges, and dangers when a utilitarian view of interpreter is constructed, imposed, and/or reinforced in health care settings. METHODS: We conducted in-depth interviews and focus groups with 26 medical interpreters from 17 different languages and cultures and 39 providers of five specialties. Grounded theory was used for data analysis. RESULTS: The utilitarian view to interpreters' roles and functions influences providers in the following areas: (a) hierarchical structure and unidirectional communication, (b) the interpreter seen as information gatekeeper, (c) the interpreter seen as provider proxy, and (d) interpreter's emotional support perceived as tools. CONCLUSION: When interpreters are viewed as passive instruments, a utilitarian approach may compromise the quality of care by silencing patients' and interpreters' voice, objectifying interpreters' emotional work, and exploiting patients' needs. PRACTICE IMPLICATIONS: Providers need to recognize that a utilitarian approach to the interpreter's role and functions may create interpersonal and ethical dilemmas that compromise the quality of care. By viewing interpreters as smart technology (rather than passive instruments), both providers and interpreters can learn from and co-evolve with each other, allowing them to maintain control over their expertise and to work as collaborators in providing quality care.

The social meanings of traditional Chinese medicine: elderly Chinese immigrants' health practice in the United States.

We situate elderly Chinese immigrants' utilization of traditional Chinese medicine (TCM) in social contexts (e.g., family and social networks), exploring how TCM is used as a tool, a resource, and a product of meaning-construction in their everyday life. We conducted in in-depth interviews with 20 elderly Chinese immigrants in the United State, exploring the complexity of their understanding and practice of TCM. We used grounded theory to identify the set of meanings that are particular to elderly Chinese immigrants' use of TCM as a part of their health practice. For our participants, TCM is not just a resource for illness management. Instead, incorporating TCM in their health practice allows them to: (a) perform and reaffirm their cultural identity as Chinese, (b) maintain their moral status and fulfill their social roles, and (c) pass down health knowledge and cultural heritage. Clinical implications were discussed.

Not all are desired: providers' views on interpreters' emotional support for patients.

OBJECTIVE: This study examines (a) providers' expectations and concerns for interpreters' emotional support, and (b) the complexity and dilemma for interpreters to offer emotional support in health care settings. METHODS: We recruited 39 providers from 5 specialties to participate in in-depth interviews or focus groups. Grounded theory was used for data analysis to identify providers' expectations and concerns for interpreters' emotional support. RESULTS: From the providers' perspective, interpreters' emotional support: (a) is embodied through their physical presence, (b) is to be both a human being but also a professional, (c) represents the extension of the providers' care, and (d) imposes potential risks to quality of care. CONCLUSION: Emotional support in bilingual health care is accomplished through the alliance of providers and interpreters, complementing each other to support patients' emotional needs. PRACTICE IMPLICATION: Interpreters should be vigilant about how their emotional support may impact the provider-patient relationship and the providers' therapeutic objectives. Interpreters should be aware that providers also rely on them to provide emotional support, which highlights the importance of giving medical talk and rapport-building talk equal attention in medical encounters.

Provider-interpreter collaboration in bilingual health care: competitions of control over interpreter-mediated interactions.

OBJECTIVE: This study examines (a) providers' and interpreters' perception of their competition in controlling the content and process of provider-patient interactions, and (b) the challenges to providers' and interpreters' collaboration in bilingual health care. METHODS: I recruited 26 professional medical interpreters from 17 languages and 39 providers from 5 specialties to participate in in-depth interviews and focus groups. Grounded theory was used for data analysis to develop themes in areas where providers and interpreters compete and assert their expertise. RESULTS: Providers and interpreters experience conflicts over their expertise and authority due to their practice in (a) adopting different speech conventions, (b) controlling the other's narratives, and (c) overstepping expertise and role boundaries. CONCLUSION: A successful bilingual medical encounter is dependent on the interpreters' and providers' ability (a) to understand, communicate, and negotiate their and others' communicative strategies/goals and (b) be adaptive of and responsive to others' management of the communicative process. PRACTICE IMPLICATIONS: Authority in bilingual health care should not be established through pre-existing categories or expertise but negotiated and coordinated during the interactive process, which would allow individuals to be adaptive to the issues emerged in the communicative process.

Dimensions of trust: the tensions and challenges in provider--interpreter trust.

In this study we examined the challenges to providers' and interpreters' collaboration in bilingual health care. We conducted in-depth interviews and focus groups with 26 medical interpreters (speaking 17 languages) and 32 providers (from four specialties) in the United States to provide an empirically based framework of provider-interpreter trust. Constant comparative analysis was used for data analysis. We identified four dimensions of trust, theoretical constructs that can strengthen or compromise provider-interpreter trust: interpreter competence, shared goals, professional boundaries, and established patterns of collaboration. In this article we describe how these dimensions highlight tensions and challenges that are unique in provider-interpreter relationships. We conclude with practical guidelines that can enhance provider-interpreter trust, and propose future research directions in bilingual health care.

"I am not a robot!" Interpreters' views of their roles in health care settings.

In this study, I examined interpreters' self-perceived roles and their corresponding communicative goals and strategies. Twenty-six professional interpreters (of 17 languages), 4 patients, and 12 health care providers were recruited for this study, which involved participant observation of medical encounters and in-depth interviews. Constant comparative analysis was used to generate a typology of interpreters' self-perceived roles, which are different from the roles they learned in their training. Different roles reflect differences in interpreters' concern for other participants' goals, institutional goals, and their own communicative goals. Interpreters' desire to maintain neutrality during the medical encounters influences the communicative strategies they adopt when assuming other roles. I conclude the article with the theoretical and practical implications of interpreters' self-perceived roles.