Wednesday 23 April 2014

Breaking Down Barriers: For the deaf, a doctor who can communicate

Darrell Sapp/Post-Gazette

Dr. Deborah Gilboa signs with her patient Yvonne Wilt , of Swissvale, during her visit at the Squirrel Hill Health Center. Dr. Gilboa is one of the few doctors in the nation who is fluent in American Sign Language.
November 25, 2013 12:00 AM
By Tina Calabro

Deborah Gilboa had an unconventional path not only to becoming a family practice physician but also to becoming one of the few doctors in the nation who is fluent in American Sign Language.
After completing a bachelor's degree in theater at Carnegie Mellon University in 1992, the Chicago native took a job as stage manager with Deaf West Theater in Los Angeles. It was a transformational experience. Immersed in deaf culture, she was surprised at how frequently her colleagues spoke about their difficulties communicating with doctors. As someone considering medicine as a career, she paid close attention.
Upon returning to Pittsburgh to complete prerequisites for admission to medical school, Dr. Gilboa became a certified ASL interpreter. Throughout medical school at the University of Pittsburgh, she gained valuable experience by interpreting in emergency rooms and other health care settings. When she finished her degree, she joined the staff of the Squirrel Hill Health Center, a federally funded agency whose mission is to remove barriers to high quality health care, including communication barriers. Patients who use the center, including many immigrants and refugees, speak numerous languages, all of which are accommodated by bilingual staff or interpreters.
Resources for people who are deaf and hard of hearing
 Pennsylvania Office for Deaf and Hard of Hearing (www.dli.state.pa.us/odhh) provides information and advocates for accessibility.
 HealthBridges (http://healthbridges.info) provides resources for people who are deaf or hard of hearing and helps health care providers understand accommodations and disability rights.
 The City of Pittsburgh/Allegheny County Task Force on Disabilities has a publication on hospital compliance guidelines for people who are deaf, deaf-blind or hard of hearing: www.pittsburghpa.gov/dcp/files/ada/11_ADA_Hospital_Compliance_Guidelines.pdf
"Deborah's ability in ASL made her attractive to us," said Susan Friedberg Kalson, CEO of the center. "She has such empathy for people who have overcome barriers to get health care."
People who are deaf or hard-of-hearing are said to be one of most underserved disability populations in terms of health care. Lack of sign language interpretation is the most frequent subject of Department of Justice cases regarding compliance with the Americans with Disabilities Act in health care settings, according to the website ada.gov.
The ADA requires medical facilities to provide "appropriate auxiliary aids and services when necessary to ensure effective communication." Besides lawsuits, the negative consequences of forgoing such accommodations can range from minor misunderstandings to life-threatening situations.
Amid the call for greater compliance with the law, awareness seems to be growing in the health care world. Interviews with representatives of UPMC's Disabilities Resource Center and two hospitals in the Allegheny Health Network (Allegheny General and Jefferson Regional) revealed commitment to providing accommodations for inpatients and outpatients through a combination of live interpreters, video remote interpreting, assistive listening devices and ongoing staff training. An addition to UPMC facilities is video relay phone service for inpatient use.
People who are deaf or hard of hearing are estimated to be about 10 percent of the population, said Amy Hart, CEO of the Center for Hearing and Deaf Services, the largest regional provider of interpreters and related services. Of that 10 percent, about 6 percent are "culturally deaf," meaning they use sign language as their first language.
Over the past year, the center has fulfilled 6,000 requests for interpreters in health care settings in 22 counties. Two-thirds of the requests came from hospitals; one-third from private practices. According to Ms. Hart, the main barriers that keep health care providers from using ASL interpreters seem to be not understanding the obligation to do so under the law and resistance to the cost of interpreters, which typically range from $40 to $60 per hour.
The center receives calls weekly from patients who complain about difficulty in obtaining ASL interpretation in health care. Some report that they are asked to bring their own interpreters, use family or friends as interpreters, or choose other facilities that provide ASL. In many cases, the patient acquiesces in order to maintain the relationship with the doctor. But sign language interpretation is "not just a convenience," said Ms. Hart. "It's a critical part of health care."
Dr. Gilboa sees more than 100 patients who are deaf and speaks nationally to physicians about understanding this population. She says that using handwritten notes is not sufficient. "We need to communicate in a way that is best for the patient, not for us."
At the same time, she says, hiring sign language interpreters can be "a huge burden" on physicians. "Many have to pay out of pocket. Insurance doesn't help at all. There's a huge disincentive. It's not as simple as saying 'those poor people and those mean doctors.' There's a real tension."
But the real bottom line is that effective care is not possible without adequate communication, she says. "When I see a new patient who is deaf, often the patient will express health problems to me that they have never expressed before because of the difficulty of communicating with doctors in the past. For example, they might not know the results of tests."
Chris Noschese, a patient of Dr. Gilboa and a leader in the deaf community, said that before choosing Dr. Gilboa as his physician a few years ago, he frequently wrote notes back and forth with his doctor during appointments. "It took so much time, and doctors are short on time. With someone who knows ASL, I can express myself freely. I can ask a question. We can really communicate."
Michelle Ruotolo, 33, of Penn Hills, who delivered her first child a year ago at Magee-Womens Hospital of UPMC, said it was an outstanding experience because she was provided with a sign language interpreter at every prenatal visit and during the delivery. "When you're giving birth, nurses and other people are coming and going all the time. How would I know what was going on without an interpreter?"
The use of video remote interpreting, which involves video conferencing with a sign language interpreter during a medical visit, is growing rapidly. "It's immediately available and for quick procedures, like blood draws, it can be cheaper than an interpreter," said Ms. Hart. "It can also work well as a bridge to a live interpreter."
She noted, however, that many in the deaf community oppose its use in medical settings. "It doesn't give nearly the information that a live interpreter can."
Dr. Gilboa continues to advocate for optimal communication between doctors and deaf patients. "The deaf community puts up with uncertainty about their health care that leaves them poorer for it, and I don't mean financially," she said. "As doctors, we want to know what's really going on. The deaf community's expectations of doctors is very low. We need to raise those expectations."

Health care resources for people who are deaf and hard of hearing:
 Pennsylvania Office for Deaf and Hard of Hearing (www.dli.state.pa.us/odhh) provides information and advocates for accessibility.
 HealthBridges (http://healthbridges.info) provides resources for people who are deaf or hard of hearing and helps health care providers understand accommodations and disability rights.
 The City of Pittsburgh/Allegheny County Task Force on Disabilities has a publication on hospital compliance guidelines for people who are deaf, deaf-blind or hard of hearing: www.pittsburghpa.gov/dcp/files/ada/11_ADA_Hospital_Compliance_Guidelines.pdf

The Impact of Language Barrier & Cultural Differences on Restaurant Experiences:
A Grounded Theory Approach

Ellen Eun Kyoo Kim
The School of Hospitality Management
The Pennsylvania State University
and

Anna S. Mattila
The School of Hospitality Management
The Pennsylvania State University

ABSTRACT

he issue of language barriers is particularly critical during intercultural service
encounters for ESL (English as a Second Language) customers. Customers may struggle to
communicate what they want or even get necessary information regarding products or services.
Through a qualitative study, based on a grounded theory approach, this study identifies issues
that concern ESL customers in intercultural service encounters. The findings suggest that the
language barrier generates negative emotional and cognitive responses, and prevents ESL
customers from taking certain actions such as seeking necessary information or complaining
about service failures.
KEY WORDS: grounded theory, language barrier, intercultural service encounter, ESL
customers
INTRODUCTION
“The limits of our language” means the limits of our world.
-Wittgenstein, 1922, p. 149-
Increased globalization is forcing a growing number of business managers and employees
to interact across linguistic boundaries (Lauring, 2008). Since language affects almost all aspects
of everyday life, there needs more of a focus on communication barriers by researchers and
practitioners engaged in international business and management (Henderson, 2005). The issue of
language barriers is particularly critical during intercultural service encounters. Intercultural
service encounters, where the customer and the service provider are from different cultures, is
very common in the service sector, especially in the U.S. (Czinkota & Ronkainen, 2002). Such
intercultural service encounters may be influenced not only by cultural differences but also by
language barriers. The fact that most service providers in the U.S. only speak English may
greatly affect international customers. Customers may find it difficult to communicate or even
get necessary information regarding products or services.
Despite its importance, the effects of language barriers on ESL (English as a Second
Language) customers’ service experiences have been largely neglected in academic research.
Language is not only a medium of communication, but also linked to an individual’s identity
(Lauring, 2008) therefore these barriers may influence various aspects of the service experience.
Applying this notion to the U.S. restaurant context, this study aims to investigate the impact of
language barrier on ESL customers’ dining experiences in the U.S. Through qualitative and
exploratory methods, this study will identify issues that concern ESL customers in intercultural
service encounters and the results of this study will help restaurant firms to create a better service
experience for ESL customers.
LITERATURE REVIEW
Language is the key to a person’s self-identity. It enables the person to express emotions,
share feelings, tell stories, and convey complex messages and knowledge. Language is our
greatest mediator that allows us to relate and understand each other (Imberti, 2007). It can be
defined as a system of conceptual symbols that allows us to communicate. It also provides us
with a significant frame of reference and a relational context that sustains our identities (Imberti,
2007). The social identity theory (Tajfel, 1974; Tajfel & Turner, 1979) focuses on the
understanding of psychological processes driving intergroup discrimination. The categorization
of in-groups versus out-groups can be generated when customers recognize certain cues, such as
language, that delineate cultural differences (Brickson, 2000; Nkomo and Cox, 1996). Not being
able to identify with other cultural groups may lead to negative attitudes towards such groups
(Bartel, 2001). A sense of ignorance due to such differences can prevent ESL customers from
interacting with domestic servers (Baker & Haretl, 2004). Consequently, the understanding of
the link between language and social identity patterns is of great importance to the international
business community. Surprisingly, literature is silent regarding the effects of language barriers
on ESL customers. However, literature on intercultural service encounters and low literate
consumers may be relevant
Literature on intercultural services marketing seems to run counter to the notion of the
social identification theory. While the social identification theory suggests that not being able to
identify with other cultural groups leads to negative consequences, studies on intercultural
services argue that customers adjust their service evaluation standards and tend to be more
understanding in intercultural service encounters. For example, Strauss and Mang (1999) state
that customers do not perceive inter-cultural encounters to be more problematic than intracultural
encounters. Warden et al. (2003) agree with this notion and states that customers are
more forgiving of service failures in the context of intercultural encounters. However, it is
noteworthy that these studies do not examine the emotional and cognitive mechanisms that
customers may go through when interacting with inter-cultural service providers.
ESL consumers can also be perceived as low literate customers in terms of their English
skills. They struggle not only with reading and writing but also with listening and speaking
English. Low literacy levels are associated with a range of negative market outcomes. Adkins
and Ozanne (1998) identified problems encountered by low literate consumers ranging from
choosing the wrong product to misunderstanding pricing information. Similarly, Viswanathan, et
al. (2003) found that low literate consumers experience difficulties with effort versus accuracy
trade-offs when making purchase decisions.
Overall, previous studies suggest that language is more than just a communication tool
(Imberti, 2007; Lauring, 2008) and can influence different aspects of the service encounter for
ESL customers. Accordingly, it is essential to better understand how language barriers affect
ESL customers’ service experience.
METHODOLOGY
Given the exploratory nature of this study, grounded theory was adopted as the
methodological framework for data collection and analysis (Charmaz, Glaser and Strauss, 1967,
Strauss and Corbin, 1990).
Qualitative interviews were used as the main source of data. The face-to-face, semistructured
interviews were conducted in Korean, averaging an hour in duration. An interview
protocol consisted of 15 questions probing the interviewees regarding their typical restaurant
experiences in the U.S., which included their interaction with service providers, service failures
and complaint experiences, overall satisfaction, and intention to return. During the interviews,
the interviewees were asked additional questions and comments. Each interview was audiorecorded
and transcribed in Korean. Nine interviewees were recruited for this study by reference
sampling. The profile of interviewees is presented in Table 1.
Table 1. Profile of Interviewees
Interviewee Gender Age Time spent in the US Status in the U.S.
Participant 1 F 29 4 months Student
Participant 2 M 25 3 months Student
Participant 3 F 27 4 months Student
Participant 4 F 33 3 weeks Tourist
Participant 5 M 47 6 years Resident
Participant 6 F 58 4 weeks Tourist
Participant 7 M 25 2 weeks Tourist
Participant 8 F 22 6 weeks Tourist
Participant 9 M 30 1 week Tourist
First order and second order data were extracted following coding procedures based on
grounded theory (Charmaz, 2006; Van Maanen, 1979). At the initial stage, open-coding enabled
us to stay close to the raw data. We also labeled and coded any meaningful statements in the
transcription. The second stage applied selective coding to synthesize large amounts of data and
to identify main themes. During this stage, the constant comparative method was used to
compare within and across interviews as an iterative interpretation of data (Glaser and Strauss,
1967).
Next, theoretical coding procedure was conducted to capture the first order data. The
themes identified in the previous stage were used as a basis to develop abstract levels of
theoretical coding. A model that explains the phenomenon discovered in the first order analysis
was developed by investigating the relationships between each theoretical codes. During this
process, dimensions and concepts developed by the data were compared with prior literature to
facilitate interpretation of the data. Incorporating the findings from these procedures, the final
conceptual model was developed based on a sequence of the dining process (see Figure 1). Every
coding and analysis was processed in Korean and later translated into English.
Taking into account the interpretative nature of grounded theory, the four criteria
proposed by Lincoln and Guba (1985) – credibility, transferability, dependability, and
conformability – were used to tackle the trustworthiness issue. Trustworthiness was achieved by
ensuring referential adequacy and preparing sufficient description of the data. Additionally, each
interviewee was asked to read the Korean transcript of his/her own interview.
FINDINGS
In the first order analysis, 46 themes were identified which fall under the categories of 1)
language 2) cultural differences 3) sensing problems 4) emotional and cognitive reactions 5)
coping behaviors 6) evaluations 7) experience and knowledge (See Table 2). Some key findings
are discussed in the following section.
Table 2. First order themes and second order concepts with representative quotes
1) Language:
_ Speaking: “ I didn’t know how to order in English. I didn’t even know how to say simple
things like “I want this….’”
_ Listening: “Sometimes, I don’t understand because the server talks too fast.”
2) Cultural differences:
_ Ordering system (customization): “Unexpected things…, like ‘how would you like your
eggs?’ then I really have no idea what to say…”
_ Menu (type of food): “I don’t know what kinds of bread and dressings there are to choose
from..”
_ Paying system: “Why do they always make us wait? What can’t we just pay at the
cashier?”
_ Relationship between customer & employee: “They are too friendly…they don’t respect
us enough.”
_ Service style: “They seem to check on us too often.”
3) Sensing problems:
_ Communication: “Obviously, we (service provider and I) struggle to communicate with
each other.”
_ Accuracy: “Then I can’t get the information I need... I question whether I heard
correctly…”
_ Purchase decision: “So I just end up ordering whatever because I don’t know…”
4): Emotional/cognitive reactions:
_ Emotional response: “Not being able to communicate doesn’t end there …it makes me
feel stupid and I get embarrassed…”
_ Cognitive response: “So I get confused… what am I supposed to say at this point?”
5) Coping behaviors:
_ Ask/not ask: “I just don’t bother to ask again to the server.”
_ Complain/not complain: “I don’t bother to complain…”
_ Blame self/other: “Somehow I end up blaming myself for not knowing…”
6) Evaluations:
_ Satisfied/dissatisfied: “I am usually satisfied as long as the food tastes good…”
7) Experience & knowledge:
_ “Once I learn the system, like the ordering system, then I do better next time.”
Language
All interviewees pointed out language barrier as the main reason for stress. Interviewees
mentioned that the difficulties in expressing themselves or understanding what the servers were
saying were the main problems. Due to such obstacles, they blame themselves for the problems
they encounter unless the service failure was severe and obvious.
Cultural differences
Most of the cultural differences in the dining experience reflected the different restaurant
systems in the U.S. and Korea. Customization (ordering system) was the main difference that
Korean ESL customers found “difficult.” This is surprising considering prior studies suggest that
customization leads to higher satisfaction, more positive attitude, and greater willingness to pay
more (Goldsmith & Frieden, 2004). However, Korean customers found customization to be
stressful. Korean customers are not familiar with customization such as choosing different kinds
of bread, cheese, or salad dressing. In fact, they are not familiar with or enjoy being asked what
options they preferred.
Another major cultural difference that surfaced was the service style of American servers.
They mentioned that American servers were too friendly and not formal enough. This may be
due to the “power distance” that are familiar to Koreans and not Americans. Power distance is
“the extent to which the less powerful members of institutions and organization within a country
expect and accept that power is distributed unequally.” (Hofstede and Hofstede, 2005, p.45).
Korean customers, who have a high power distance culture, especially in the food service
industry, perceive the social position of the customers to be higher than front-line service
providers (Mattila, 1999). Thus, Korean ESL customers find it different and even unpleasant that
American servers treat their customers as equals.
Sensing problems
Miscommunication and the difficulties in obtaining accurate information on the menu
items are the main sensing problems that Korean ESL customers encounter. This, in turn, affects
their purchase decisions because they are not well-informed about the products and procedures.
Emotional/cognitive reactions
Emotional responses that ESL Korean customers experienced most frequently were
anxiety, fear, and embarrassment. They were anxious due to a lack of knowledge such as not
knowing the type of food, or not knowing what to answer when servers asked questions. Fear
was mainly related to “face consciousness.” The interviewees were afraid that they were going to
be embarrassed in front of the server or their friends, and embarrassment is the emotion they
experienced when they lost face. According to Ho (1979), face is defined as the reputation and
the credibility one has earned in a social network. Prior studies show evidence that Asians are
more face-sensitive than Westerners (Ho, 1991). On the other hand, their cognitive response was
mainly confusion which comes from not knowing how to react to unexpected situations or when
they don’t understand what the servers were saying.
Coping behaviors
Coping behaviors are closely related to sensing problems and are largely affected by
emotional responses. Interviewees identified embarrassment, fear, and anxiety as the emotions
they encounter. Their coping behaviors such as not asking the server or not complaining unless
the service failure is severe may reflect their behavioral responses to such emotions. Their
coping behaviors were severely affected by the server’s attitude. When the server was attentive,
ESL customers were encouraged to ask the server questions or to complain if there were
problems. However, when the server was unfriendly, they were reluctant to do so. Since service
recovery to customer complaints increases satisfaction and loyalty (McCollough, et al., 2000),
training employees regarding cultural backgrounds of ESL customers and educating them to be
more attentive and friendly is essentia
Evaluations
All nine interviewees pointed out that their expectation level is relatively low in terms of
service. Since they do not enjoy interacting with service providers due to language barriers, t
evaluations are based more on other tangible
such as when it was salient that the server was rude
“discrimination,” thus reacting negatively
Experience and Knowledge
For ESL customers, the dining experience
knowledge which later guides them through their next dining process. The more experience they
gain, the less likely they will encounter problems or even feel
However, the language barrier st
Figure 1. Final conceptual model
Note. Arrows indicate sequential relationships
LIMITATIONS AND FUTURE STUDIES
English is a unique language. Especially to Koreans, English means more than just a
foreign language. The Korean education system requires Koreans to learn English as a
mandatory course. Therefore, not being able to speak English may generate shame and spe
English well may evoke pride for Koreans. Future studies can observe ESL Koreans in other
non-English speaking countries to broaden the scope of this study.
Koreans are North-East Asians with certain cultural characteristics. They share cultural
values such as high power distance, high collectivism, and high face concerns. Future studies can
observe how cultural factors affect the impact of language barrier by comparing Korean ESL
customers to other ESL customers from different cultural backgrounds,
customers. The interviewees of this study mentioned about “losing face” and “feeling
raining essential.
attributes. However, when they were treated badly
rude, they seemed to perceive it as
negatively.
process counts toward their experience and
a negative emotional respons
still remains until their English skills improve.
lues such as Hispanic ESL
their
badly,
response.
speaking
embarrassed” which led to their coping behaviors such as “not complaining.” However, Hispanic
ESL customers might not be as concerned about “losing face” and may feel more “angry” than
“embarrassed” which may lead to different coping behaviors such as “complaining.”
Lastly, interviewees of this study showed different levels of dining experiences in the U.S.
as well as different levels of prior dining experiences in Korea. The female interviewees were
more experienced than their male counterparts.
REFERENCES
Adkin, N. R., & Ozanne, J. L. (2005). The Low Literate Consumer. Journal of Consumer
Research, 32, 93-105.
Bartel, C.A. (2001) ‘Social Comparisons in Boundary-spanning Work: Effects of Community
Outreach on Members’ Organizational Identity and Identification’, Administrative
Science Quarterly 46: 379–413.
Barker, S., & Haertel, C. E. J. (2004). Intercultural service encounters: an exploratory study of
customer experiences. Cross Cultural Management, 11(1), 3-14.
Brickson, S. (2000). The Impact of Identity Orientation on Individual and Organizational
Outcomes in Demographically Diverse Settings. Academy of Management Review, 25(1),
82-101.
Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide Through Qualitative
Analysis. Thousand Harper Row.
Czinkota, R. C., & Ronkainen, L. (2002). International Marketing. Fort Worth, TX: Harcout
College Publishers.
Dalton, M. and Chrobot-Mason, D. (2007) ‘A Theoretical Exploration of Manager and Employee
Social Identity, Cultural Values and Identity Conflict Management’, International
Journal of Cross Cultural Management 7(2): 169–83.
Glaser, B. G., & Strauss, A. K. (1967). The discovery of grounded theory. New York. NY:
Aldine de Gruyter.
Henderson, J.K. (2005) ‘Language Diversity in International Management Teams’, International
Studies of Management and Organization 35(1): 66–82.
Ho, D. Y. F. (1979). ‘Psychological implications of collectivism: with special reference to the
Chinese case and Maoist dialectics’. In Eckensberger, L., Lonner, J. and Poortinga, Y. H.
(Eds), Cross-Cultural Contributions to Psychology. Lisse, Netherlands: Swets &
Zeitlinger, 143–50.
Ho, D. (1991). The concept of ‘face’ in the Chinese–American interaction. In: W.-C. Hu & C. L.
Grove, eds. Encountering the Chinese: a Guide for Americans, pp. 111–124. Yarmouth,
ME: Intercultural Press. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry.
Beverly Hills, CA: Sage.
Imberti, P. (2007). Who resides behind the words? Exploring and understanding the language
experience of the non-English speaking immigrant. Families in Society, 88(1), 67-73.
Lauring, J. (2008). Rethinking social identity theory in international encounters: language use as
a negotiated object for identity making. International Journal of Cross Cultural
Management, 8, 343.
Mattila, A. S. (1999). The role of culture and purchase motivation in service encounter
evaluations. Journal of Services Marketing, 13(4/5). 376-389.
Nkomo, S. M., & Cox T. H. (1996). Diverse Identities in Organization. In S. Clegg, C. Hardy
and W. Nord (Eds), Handbook of Organization Studies (pp. 338-356). London, England:
Sage Publications.
Stauss, B., & Mang, P. (1999). “Cultural Shocks” in Inter-Cultural Service Encounters? Journal
of Services Marketing, 13(4/5), 329-346.
Stauss, A. L., & Corbin, J. M. (1990). Basics of qualitative research. Newbury Park, CA: Sage.
Tajfel, H. (1974). Social Identity and Intergroup Behavior. Soc. Sci. Inf, 13, 65-93.
Tajfel, H., & Turner, J. M. (1979). An Integrative Theory of Intergroup Conflick. In W. G.
Austin and S. Worchel (Eds.), The Social Psychology of Intergroup Relations (pp. 94-
109). Monterey, CA: Brooks-Cole.
Van Maan, J. (1979). The fact of fiction in organizational ethnography. Administrative Science
Quarterly, 24, 539-550.
Viswanathan, M., Rosa, J. A., & Harris, J. E. (2003). Towards Understanding Functionally
Illiterate Consumers. Unpublished working paper, Department of Marketing, University
of Illinois, Urbana-Champaign, IL 61820.
Warden, C. A., Liu, T. C., Huang, C. T., & Lee, C. H. (2003). Service failures away from home:
benefits in intercultural service encounters. International Journal of Service Industry
management, 14(4), 436-457.