“Would you Decide to Keep the Power?”: Reflexivity on the Interviewer–Interpreter–Interviewee Triad in Interviews with Female Punjabi Rheumatoid Arthritis Patients

Tessa's reflections.

Control over a situation is an indicator of power. Control during the interpreted interviews was challenged for different reasons for Kanta, the interviewees, and me. My power originates from being the grant holder for the project and directing the research. Figure 1, however, indicates how my knowledge is restricted to that related to research, which consists of research skills, the literature related to the project, and my previous research that led to this particular project. Direct cultural knowledge is limited to travelling through the Indian Punjab region in the year 2000. In comparison with previous interview studies, I was aware that I would have to relinquish some control over the interview process because of the need for interpretation and interviewing through an intermediary. Part of relinquishing control was sanctioned formally at the outset through inviting Kanta to ask questions that addressed issues that I may have missed during the interviews (particularly through lack of cultural knowledge, but also as evident from her clinical experience).

This invitation arose from recognition of her multiple identities and different streams of knowledge:

Nevertheless, I had not anticipated that some of my control would be lost unwillingly, and this was disconcerting. Control was lost when I felt that questions were being clarified without being able to form those questions myself and when opportunities were missed to probe on talk that was pertinent to the research because of a delay in interpretation. This loss of control is evident in this reflection:

Over the course of the interviews, debriefings between Kanta and me clarified how we worked together and as a result I felt more comfortable “giving away control” (Tessa, line 564), rather than having a sense of losing it. I saw evidence in the transcripts that Kanta focused on accurately interpreting the meaning of the talk, even when specific words were not interpreted during the interview because of necessary précising (but were there in the translations she made later). I also realised that the iterative process of using analysis of earlier interviews to inform later ones enabled me to explore interesting data and emerging theory with later interviewees.

Kanta's reflections.

A challenge to my control of the situation was instigated by coming out of my professional role to establish a friendly relationship in an unfamiliar situation for the interviewee (i.e., the research interview) and acting differently towards that person than in my clinical role. This was a potentially vulnerable position, which I wanted to limit in order to then be able to re-establish a professional identity:

It was important that the interviewees knew I was a health professional and a researcher in addition to acting as an interpreter for the duration of the interview. None of the participants were previously or currently under my care, but communicating a professional identity was important in case of future clinical contact. It also explained my role, for example, in escorting participants through the hospital to the interview setting. From using interpreters in clinical encounters, I was aware that patients experienced most interpreters as disinterested, and therefore I wanted to disassociate myself from them and that perception of them:

It appeared that the participants also experienced a challenge to their sense of control of the situation. This was initiated through the act of participating in research, which was an unfamiliar interaction. Although the interviews took place in the rheumatology department where the participants attended appointments, an unfamiliar room was used:

In addition, signing a consent form and having the interview recorded were unfamiliar occurrences that signalled a shift of control:

Reiteration of the reasons for obtaining consent and recording their voices was a vital part of the interaction. Reassurance was given that respondents' negative views would not impact their care. The voluntary nature of participation was emphasised to signal that they were able to cease the interview at any point without consequence, and therefore they maintained control over their participation. The key factor throughout the interview was to ensure that patients felt comfortable enough to talk about issues that they had perhaps not spoken about before. The reassurance and presence of the co-researcher allowed the patients an opportunity to discuss openly about their well-being and disease-specific issues. Patients became very aware that the setting gave them permission to hold conversation through the researcher. At the end of the interviews, we asked whether there was anything that was important to the participant that we had not raised. This enabled the interviewee to take some control at the end of the interview to communicate what was most salient to her.

Fourteen of the interviews took place in rheumatology departments and two at participants' workplaces. A decision was made not to conduct interviews in the environment of their homes, where it may have been difficult to focus on the participants' accounts in households where other family members would be present. The research setting, therefore, may have affected the participants' sense of control, by removing them from a potentially non-threatening home space to one (in the case of the rheumatology departments) where their control may be challenged by increasing the power of the “healthy” interviewers over the “ill” interviewees. However, Tessa was visibly pregnant at the time of the interviews and this provided a common source of talk before and after the formal interview, where participants were interested in the researcher's body and feelings, showing an awareness of a changing body, if not an ill one.

Tessa's reflections.

In the reflexive interviews, it is evident that I positioned myself as an outsider from the outset due to not speaking the Punjabi language and not having “lived” or “embodied” cultural knowledge. I therefore relied on Kanta to act as a cultural conduit to enable data collection with those that spoke no or minimal English and to provide contextual support for data analysis across all participants. I noticed a number of practical consequences resulting from the language barrier and Kanta providing a cultural gateway. First, it was a challenge to build verbal rapport with the non-English speaking participants through her rather than directly. This was difficult because where I would normally engage in informal conversation while we settled into the room, the need for an interpreter appeared to formalise the interaction and make small talk stilted. Second, I relied more heavily on my interpretation of their non-verbal communication and reciprocation of it to build rapport and understand the emotional tone of talk. However, this was not always reliable. For example, it was difficult to make a timely response to sensitive information or issues because of the delay of interpretation. The most uncomfortable experience was where I understood after interpretation that the interviewee's husband had died. Although the interviewee was aware that I would understand only through interpretation, it felt awkward to me to have a delay in response to an emotional disclosure of this magnitude:

Third, I was concerned about offending participants if I asked about issues that might be sensitive or stigmatised in their community. For example, the stigmatisation of illness and disability within the Punjabi community arose in the interviews (Sanderson, Calnan, & Kumar, in review), and I was unsure whether participants would be comfortable about or open to talking to me as an outsider about these issues. As the project progressed, I realised that it was the sensitivity and appropriateness of questions that was important, rather than my outsider status with these participants. A useful strategy was to transfer the source of the question to previous interviewees. For example, saying “Others in your community have talked about the stigma of illness as a problem. What is your experience?” Fourth, advantageously, I explicitly used my status as an outsider to elicit explanations about cultural values and norms where understanding is assumed. For example, a participant was explaining how daughters are relied upon for support in Asian families and said to Kanta, “Well, you know how it is with us,” and I was able to ask her to explain in detail for me as an outsider. In the reflexive interview, I described how by positioning myself as “Other,” I was able to elicit explanations about values and experiences that may be left unspoken between those who assume they share the same culture:

The transcripts of the interpreted interviews show that I made attempts to show that I had some relevant cultural knowledge, such as knowing the names of Punjabi dishes. On reflection, this was to establish my legitimacy for my interest in conducting research with this specific group. Therefore, my lack of cultural knowledge was a potential threat to my control of the research but also could be used advantageously.

Kanta's reflections.

The feeling of being an outsider was applicable to the research study itself. I initially positioned myself as a translator and therefore relatively distant from the research aims, but later I exhibited an interest about the content of the patient conversation and revealed my researcher identity to Laura:

So my role in this particular project has been as a translator. (Kanta, line 7)

My request for permission to ask a question signals that I perceived Tessa as holding the dominant questioning power. However, during the period of data collection a shift occurred in my position, from interpreter only to co-researcher, as we learned to work together. This is evident in our decision to let the participant talk more freely, without “breaking the conversation,” because interviewees were becoming frustrated:

Instead, we agreed that I would interpret larger amounts of talk, focusing on conveying what appeared to be most important to the interviewee and in relation to the research aims during the interview, and then I would translate the transcript fully later. This required a continuing dialogue between us as researchers about the unfolding themes and theories in the data. This also enabled me to re-position as an insider in relation to the research study. I had worried that “Tessa had a second-hand story” (Kanta, line 607) because of my interpretation of the interviewees' answers. Nevertheless, through working closely and developing trust between us, it was evident that rich interview data were being obtained.

Interviewees appeared to position themselves as outsiders to the academic discourse and the research setting. This was most explicit where unfamiliarity with the research process led to initial feelings of uneasiness, as discussed above. Another way in which interviewees positioned themselves as outside of the academic discourse was through a perceived lack of education. This manifested in the interviews as statements of not knowing the answer to questions because of a lack of education or being unsure of the “correctness” of their talk:

Participants' unfamiliarity with reflecting on their lives appeared to result in difficulty in answering more abstract questions, particularly ones not in their first language:

Practically speaking, this meant that open questions, such as “Tell me about your health,” that had been used successfully in previous research (Sanderson et al., 2010) made the interviewees uncomfortable. Perhaps they were more familiar with closed questions and found silence, meant to enable them to think about the question, awkward. As a result, more reassurance about the value and importance of their experience was required:

Although we gave prominence to the patients' experiential knowledge, through the act of conducting research on this topic and stating explicitly to them that we valued their experience of living with rheumatoid arthritis, it appears that these particular interviewees did not themselves value this experiential knowledge. This is in contrast to previous research where White British patients claimed expertise through their experiential knowledge and even valued it more highly than health professionals' training and biomedical knowledge (Sanderson & Angouri, in review). Instead, by asking whether they were giving the correct answers they presumed we had greater knowledge and thus diminished their potential power in the interaction.

Tessa's reflections.

A decision was made in the design of the study to use a co-researcher with the appropriate language skills, rather than a professional interpreter. The three roles that Kanta brought into the interview interaction (interpreter, researcher, and nurse) were reflected in the streams of knowledge drawn upon in the interviews. First, there were times during the interview when she would draw on her clinical experience and knowledge, for example using a medical term when the participant had used a less technical phrase and/or adding a clinical commentary:

In addition, Kanta occasionally switched into a clinical role when there was a particular care need identified and she was conscious of this identity and role shift. We agreed that this was a necessary and appropriate response. For example:

Second, Kanta could be seen as enacting a research identity by making links between the current data and her research knowledge, particularly her own previous studies:

Kanta's reflection on her own previous research was helpful for me during the interviews to provide context for the participant's illness experience, but it had to be carefully managed during analysis to distinguish who had contributed what in the co-construction of the interview data. I was aware that Kanta was involved in a “juggling act” (Tessa, line 581), and in retrospect it would have been beneficial to discuss managing potentially conflicting roles prior to commencing and during the data collection period.

Kanta's reflections.

My three different identities (interpreter, co-researcher, and nurse) were expressed during the interviews and had implications for positioning myself in relation to Tessa and the interviewee. For example, in the reflective discussion, I was deliberating balancing the need to make the interviewee feel comfortable with the need for effective data collection, which included knowing when to shift control of the questions to Tessa:

It could be argued that the interpreter acts as a conduit of power, transferring the opportunity to speak from the interviewer to the participant, and back again. As primarily an intermediary in the interview interaction, I was balancing Tessa's needs (and research aims) with those of the interviewee. In practice, the flow of the conversation was maintained with the interviewee until they completed their answer. Tessa then understood the interviewee's answer via my translation. Upon understanding what the patient had expressed, she then would ask further questions on the same topic or generate a new question, and thus flow was maintained throughout the interview. In some cases, I was required to continue probing as I felt that some patients gave short answers and were hesitant to expand on them. Once the interviewees were made to feel comfortable, they were able to connect with me and, by extension, Tessa, and in-depth conversation took place.

Kanta's reflections.

On meeting the interviewees, I focused on showing respect for the elder patients (those that spoke Punjabi only were all first generation). I used cultural markers of respect, such as calling them “Auntie” to indicate the social capital that an elder woman in Punjabi culture holds:

Through this change from being a research participant situated in an unfamiliar process to a respected elder, a favourable shift of power was achieved and a sense of ease was established in the relationship between us. This was achieved through our shared cultural knowledge:

The process of easing begins from the minute that you meet them. (Kanta, lines 45-6)

A shared South Asian cultural knowledge, an “ethnicity” discourse, was also commonly utilised to establish a rapport. However, one interviewee asserted a religious boundary between us, apparently deciding my Hindi heritage from my name distinguished me from her Sikh heritage:

This reinforces that although we shared some social positioning (e.g., ethnic minority and female), there were differences (e.g., age, religion, and education), and some boundaries were asserted.

Tessa's reflections.

A couple of the interviewees, where an interpreter was necessary, still tried to communicate directly with me using a few words of English. This could be interpreted in different ways, but in these interactions this direct communication by the interviewees appeared to be concerned with asserting their illness experience and their patient “voice,” by emphasising the impact of the rheumatoid arthritis to the primary researcher rather than to the intermediary, and thereby asserting a social hierarchy:

In this way, it appears that the interviewees were using experiential knowledge, or an “illness” discourse, to communicate their priorities for the academic discourse of which they were outsiders, and they could understand this academic discourse held greater influence on the outcome of the research. Through the interview interaction, it appears that the attitude of these elder Punjabi women had changed towards research from one of unfamiliarity to appreciation for the bridges that were being constructed:

To end the reflections on a positive note—my experience was that by closely listening to and valuing the interviewees' experiential knowledge, the power differentials created by educational, professional, and cultural discourses did not obstruct the interview interaction, but were constantly negotiated to enhance collaboration through mutual respect: