Distribution and sharing
Communication tools as indicators of commitment to quality of care
Cautionary Words - the limitations of communications tools
External Factors
Design Issues
Translation Issues
Communication Issues


After 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:
  • Consider each communication tool individually and briefly point out any noteworthy strengths, weaknesses and general observations.
  • Consider the tools as representing methods of communication (i.e. signs, symbols, pictograms, bilingual words and phrases and alerting the system) and identify any obvious advantages, disadvantages, problems or concerns with each.
  • Finally, the reviewers were asked to make recommendations and suggestions for any future work in relation to improving or developing cross cultural communication tools.
The interviews were transcribed, grouped into common themes and are reported below along with a number of recommendations.

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:
  • The reviewers acknowledged that local production was sometimes "kept quiet" due to a fear of cumbersome bureaucracies and complex politics that have the potential (real or perceived) to encumber or appropriate a resource developed locally with Area funding.
  • Once the resource was produced the reviewers felt that distribution depended more on "who you knew" rather than a practical, clear distribution or information sharing system.
  • Reluctance among health services to share locally produced resources either because of ownership issues or possible loss of cost recovery options from sales.
  • Issues of copyright, and prohibitive purchasing or reproduction costs prevented them from being distributed more widely.

Solutions offered to address these specific problems included:
  • Area Multicultural Health Coordinators could monitor and keep registers of multilingual resources produced locally and publicise them through Multicultural Communication [e.g. Polyglot].
  • Wherever possible, copyright could be clarified for existing resources and these, along with any new resources, could be placed on the Multicultural Health Communication Website.
  • Developing and promoting clear practical guidelines could encourage local production.

Communication tools as indicators of commitment to quality of care

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:
  • The client - for example clients with motor function impairments, cognitive impairments, physical disabilities etc, may be physically unable to use the tools. Clients, for reasons of unfamiliarity with the concept of communication tools or low literacy, may be unable to understand their purpose and function.
  • The health setting - CALD clients, in busy unfamiliar environments are confronted by a multitude of auditory and visual stimuli. The health facility ironically is far from an ideal environment to take in the health and medical information (which the signs and symbols are designed to convey). Clients may be feeling stressed overwhelmed by their own emotional reactions to the environment and the situation they find themselves in. People of CALD need to be much more motivated to actively seek and understand information than we can reasonably expect individuals to be under these circumstances.
  • The health system - Systems may not be as predictable or reliable as their designers would like them to be, nor are they as transparent as these tools imply. Health services and individual health care workers change over time and from place to place, for example, in some countries of origin there may be no such service as "occupational therapy" and therefore clients may not share a common understanding of the service being provided. Developments in medical technology make old labels like "x-ray" obsolete, leaving non-English speakers unclear about what service they are looking for or unaware that it may not always be called the same thing, even within the same facility. Anticipated responses are not always forthcoming, interpreters are not always called or are sometimes unavailable and people sometimes experience long unexpected delays. The tools rely on predictable responses to predictable situations and cannot address the confusion and distress caused by the unexpected.

Design Issues

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:
  • Be clear about what it is they want to communicate to others and why.
  • Write in full sentences in the active voice.
  • Be concise, avoid unnecessary detail, ambiguity and unintended interpretations.
Only after a communication tool has been thoughtfully developed in English can professional translators be expected to translate the material clearly and accurately into other languages.

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:
  • Some clients may prefer to use their limited English rather any kind of communication tool for personal reasons, nor may they wish to work with an interpreter. It was highlighted that, for many, communication is not just about understanding, it may also be about personal power, control of a situation or a sense of personal connection with others and a direct involvement in their own affairs.
  • Often the form of the communication defeats its function. If the communication tools are too cumbersome or complex, the health care worker and/or their clients may "choose" not to attempt to use the available communication tool or may be physically or emotionally unable to communicate under the circumstances.
  • The limitations these tools place on communication with people from other cultures may be favourable to some health care workers for whom communicating is uncomfortable, either generally or with specific individuals or cultures.


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:
  • Guidelines should be developed that govern the production and use of multilingual communication tools in health settings. The guidelines should specifically address translation, production processes, distribution and their appropriate use. Any guidelines need to reflect current policy on interpreters and bilingual staff.
  • Symbols and pictograms used in health facilities should comply with the Australian Standard where possible and be used consistently within and across facilities statewide.
  • The current collection of signs, symbols and communication tools should be seen as a snap shot of solutions to communication problems. The communication problems they represent should be analysed to inform future efforts in the field of multilingual cross-cultural communication.
  • The current tools that are considered to be most useful should be evaluated and if appropriate, updated and distributed more widely.
  • Health Care Interpreters should be made aware of the existence of these tools, as well as be involved in their development and the education and training of health care workers in relation to their use. Establish a network of bilingual health professionals who would be prepared to review documents as they are produced and at regular intervals.
This web page is managed and authorised by NSW Multicultural Health Communication Service. Last updated: 24 July, 2009