Dr Demi Krystallidou


Areas of specialism

multilingual healthcare communication; healthcare interpreting; multimodal interaction analysis; realist methodology; empathic communication; cancer communication


Research interests


Postgraduate research supervision

My publications


Krystallidou, Demi; Langewitz, Wolf; van den Muisenbergh, Maria (2020). Multilingual healthcare communication: Stumbling blocks, solutions, recommendations
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The objective is to provide guidance on multilingual and language discordant healthcare communication. We provide a critical reflection on common stumbling blocks to securing (professional) language support, as well as on the currently available solutions to language discordance in healthcare. We discuss issues pertaining to i) the assessment of the patient and healthcare professional’s language proficiency, ii) the decision making on whether to seek language support, iii) the currently available options of language support and the development of skills that ensure their effective use, iv) the inclusion of professional interpreters in the interprofessional healthcare team, and v) the transition from single- to integrated language support solutions that allow for a more comprehensive approach to multilingual healthcare communication. We present a set of recommendations for good practice. Understanding the needs, capabilities and shortcoming of the available language- support solutions and the implications arising from them can enable decision makers to make informed decisions that ensure the quality of communication and care. The integrated use of language-support solutions at different stages of care can create the conditions for effective communication, while promoting patient and family participation in the decision making process. Evidence-based interventions that can inform the implementation of solutions are required.
Schouten, Barbara; Cox, Antoon; Duran, Gozde; Kerremans, Koen; Koseoglu - Banning, Leyla; Lahdidioui, Ali; van den Muisenbergh, Maria; Schinkel, Sanne; Sungur, Hande; Suurmond, Jeanine; Zendedel, Rena; Krystallidou, Demi (2020). Mitigating language and cultural barriers in healthcare communication: Toward a holistic approach.
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Due to ongoing globalization and migration waves, healthcare providers are increasingly caring for patients from diverse cultural and/or ethnic minority backgrounds. Adequate health communication with migrants and ethnic minorities is often more difficult to establish compared to people belonging to the majority groups of a given society, because of a combination of language and cultural barriers. To address this topic, in December 2018 a symposium was organized-under the auspices of the Amsterdam Center for Health Communication-during which speakers from both academia and professional practice discussed the current state-of-the-art and brought forward innovative solutions to improve intercultural communication in healthcare. Main questions that were discussed during this symposium included: "How can language barriers in intercultural health communication be mitigated?" and "Which innovations can contribute to improving intercultural health communication?" In this paper, we discuss some answers to these questions and propose that in order to enhance intercultural communication and healthcare for migrant and ethnic minority patients, a more holistic approach to studying when, how, and for what purposes (a combination of) communication strategies should be utilized in mitigating both language and cultural barriers to decrease health disparities and improve health care for migrant and ethnic minority patients.
Krystallidou, Demi; Bylund, Carma; Pype, Peter (2020). The professional interpreter’s effect on empathic communication in medical consultations: A qualitative analysis of interaction.
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To investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it. We coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters. We identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor. In IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction. Doctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other’s communicative goals.
Krystallidou, Demi; Vaes, Lena; Devisch, Ignaas; Wens, Johan; Pype, Peter (2020). Study protocol of OncoTolk: An observational study on communication problems in language-mediated consultations with migrant oncology patients in Flanders (Belgium).
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 Effective doctor–patient communication in oncology settings can be challenging due to the complexity of the cancer disease trajectory. The challenges can become greater when doctors and patients do not share a common language and need to rely on language mediators. The aim of this study is to provide evidence-based recommendations for healthcare professionals, patients and language mediators on how to interact with each other during language-mediated consultations in oncology settings.  A systematic review of the literature on communication problems in monolingual and multilingual oncology settings will be conducted. Thirty language-mediated consultations with Turkish-speaking or Arabic-speaking cancer patients, language mediators and Dutch-speaking oncologists/haematologists will be video-recorded in three urban hospitals in Flanders, Belgium. All participants will be interviewed immediately after the consultation and 2 weeks after it by means of video-stimulated recall. Multimodal interaction analysis will be combined with qualitative content analysis to allow for the identification of communication practices when communication problems occur.  The study has been approved by the following ethics committees: Ghent University Hospital, Antwerp University Hospital, Antwerp Hospitals Network (ZNA). Results will be published via (inter)national peer-reviewed journals and the findings of the study will be communicated using a comprehensive dissemination strategy aimed at healthcare professionals, patients and language mediators.
IntroductionMethods and analysisEthics and dissemination
Theys, Laura; Krystallidou, Demi; Salaets, Heidi; Wermuth, Cornelia; Pype, Peter (2019). Emotion work in interpreter-mediated consultations: a systematic literature review.
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The objective is to identify the ways in which physicians, patients and interpreters express emotions, react to emotional expressions and/or coordinate the emotional interaction in interpreter-mediated consultations (IMCs). We systematically searched four databases and screened 10 307 articles. The following inclusion criteria were applied: 1) participants are patients with limited proficiency in the host language, physicians and professional interpreters, 2) analysis of patient-physician-interpreter interaction, 3) focus on emotions, 4) in vivo spoken language interpretation, and 5) authentic primary data. The results of 7 included studies suggest that physicians, patients and interpreters work together and verbally and paraverbally contribute to the co-construction of emotional communication (EC) in IMCs. However, a decrease in EC might still compromise the patient’s quality of care in IMCs. There is a dearth of scientific evidence of EC as an interactional process between participants in IMCs. More research on under investigated modes of communication and emotions is needed to advance our understanding. For now, EC seems to be subject to the successful interaction between participants in IMCs. Evidence-based curricula of interprofessional education between physicians and interpreters on EC in IMCs could be beneficial to the effective co-construction of EC in IMCS.
Krystallidou, Demi; Pype, Peter (2018). How interpreters influence patient participation in medical consultations: The confluence of verbal and nonverbal dimensions of interpreter-mediated clinical communication.
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To investigate i) how the patient’s participation in interaction occurs in interpreter-mediated consultations (IMCs) when the doctor provides information to the patient or tries to elicit information from them; ii) how the interpreter’s presence in the consultation influences the patient’s participation. We analyzed 20 authentic video-recorded IMCs using the A.R.T. framework, an analytical tool for the study of participation in video recorded interpreter-mediated interactions. We coded 521 doctor utterances through which doctors either provided information or tried to elicit information from the patient. In 448 of them, the interpreter established a participation and engagement framework (PEF) with the patient while translating the doctor’s utterances. In 48 cases the interpreter established a PEF with the doctor and in 25 cases the interpreter avoided establishing a PEF with either of the participants while translating the doctor’s utterances. When the interpreter established a PEF with either of the participants, they used verbal and nonverbal means that created the conditions in interaction in order to enable and/or rectify the patient’s participation. Doctors and interpreters should become more aware of their own and each other’s actions in interaction and their influence on the patient’s participation in the consultation.
Krystallidou, Demi; Salaets, Heidi; Wermuth, Cornelia; Pype, Peter (2018). EmpathicCare4All. Study protocol for the development of an educational intervention for medical and interpreting students on empathic communication in interpreter-mediated medical consultations. A study based on the Medical Research Council (MRC) framework phases 0-2.
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Although empathy is associated with positive health outcomes, doctors do not often express empathy and they fail to sufficiently respond to patients’ emotional statements. In linguistically diverse healthcare settings empathic communication is compromised even more. This has received little attention in medical education and even less in interpreter education. This project aims to develop an educational intervention for medical- and interpreting students on empathic communication in interpreter-mediated consultations. We rely on the Medical Research Council (MRC) framework for the development and evaluation of complex interventions (phases 0–2). The project will yield valuable insights into the communicative and interactional processes and resources doctors, patients and professional interpreters use in the expression and management of empathic communication in interpreter-mediated consultations.
Pype, Peter; Mertens, Fien; Helewaut, Fleur; Krystallidou, Demi (2018). Healthcare teams as complex adaptive systems: understanding team behaviour through team members' perception of interpersonal interaction.
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Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members’ interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members’ interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour. An interview study was done with 21 palliative home-care nurses, 20 community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle. All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members’ interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified. This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research.
Krystallidou, Demi; Remael, Aline; de Boe, Esther; Hendrickx, Kristin; Tsakitzidis, Giannoula; van de Geuchte, Sofie; Pype, Peter (2018). Investigating empathy in interpreter-mediated simulated consultations: An explorative study.
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To explore i) the ways in which empathic communication is expressed in interpreter-mediated consultations; ii) the interpreter's effect on the expression of empathic communication. We coded 9 video-recorded interpreter-mediated simulated consultations by using the Empathic Communication Coding System (ECCS) which we used for each interaction during interpreter-mediated consultations. We compared patients' empathic opportunities and doctors' responses as expressed by the patients and doctors and as rendered by the interpreters. In 44 of the 70 empathic opportunities there was a match between the empathic opportunities as expressed by the patients and as rendered by the interpreters. In 26 of the 70 empathic opportunities, we identified 5 shift categories (reduced emotion, omitted emotion, emotion transformed into challenge, increased challenge/progress, twisted challenge) in the interpreter's rendition to the doctor. These were accompanied by changes in the level of empathy and in the content of the doctors' empathic responses. The interpreters' renditions had an impact on the patients' empathic opportunities and on the doctors' empathic responses in one third of the coded interactions. Curricula with a focus on intercultural communication and/or empathy should consider the complexity of interpreter-mediated interaction and the interpreter's impact on the co-construction of empathy.
Krystallidou, Demi; Devisch, Ignaas; Van de Velde, Dominique; Pype, Peter (2017). Understanding patient needs without understanding the patient: The need for complementary use of professional interpreters in end-of-life care.
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High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: (i) how to safeguard patient autonomy against paternalistic interventions by family members, (ii) how to respect the relational context in which patient autonomy can be realized, and (iii) how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended.
Pype, Peter; Krystallidou, Demi; Deveugele, Myriam; Mertens, Fien; Rubinelli, Sara; Devisch, Ignaas (2017). Healthcare teams as complex adaptive systems: Focus on interpersonal interaction.
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The aim of this study is to test the feasibility of a tool to objectify the functioning of healthcare teams operating in the complexity zone, and to evaluate its usefulness in identifying areas for team quality improvement. We distributed The Complex Adaptive Leadership (CAL™) Organisational Capability Questionnaire (OCQ) to all members of one  team (n = 15) and to palliative care physicians in Flanders, Belgium (n = 15). Group discussions were held on feasibility aspects and on the low scoring topics. Data was analysed calculating descriptive statistics (sum score, mean and standard deviation). The one sample T-Test was used to detect differences within each group. Both groups of participants reached mean scores ranging from good to excellent. The one sample T test showed statistically significant differences between participants’ sum scores within each group (p < 0,001). Group discussion led to suggestions for quality improvement e.g. enhanced feedback strategies between team members. The questionnaire used in our study shows to be a feasible and useful instrument for the evaluation of the palliative care teams’ day-to-day operations and to identify areas for quality improvement. The CAL™OCQ is a promising instrument to evaluate any healthcare team functioning. A group discussion on the questionnaire scores can serve as a starting point to identify targets for quality improvement initiatives.
Krystallidou, Demi; Van de Walle, Céline; Deveugele, Myriam; Dougali, Evangelia; Mertens, Fien; Truwant, Amélie; Van Praet, Ellen; Pype, Peter (2017). Training doctor-minded interpreters and interpreter-minded doctors: First insights into the benefits of collaborative practice in interpreter training.
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In response to calls in the literature for more collaborative practice in interpreter training, this paper describes the design, implementation and part of the evaluation of an innovative joint training intervention for interpreting students (Master’s level) and 3rd- and 4th-year medical students at Ghent University. In order to assess the development of the students’ knowledge and skills, we employed self-efficacy questionnaires; the training intervention was evaluated in a debriefing session with trainers from both fields. A development in skills that involve direct interaction with the primary participants and address specific communicative goals was noted. Our initial evaluation suggests that interprofessional education and collaborative practice in interpreter training can create the conditions for interpreting students to develop a more insightful and reflective approach to their interpreting practice.
Li, Shuangyu; Gerwing, Jennifer; Krystallidou, Demi; Rowlands, Angela; Cox, Antoon; Pype, Peter (2017). Interaction: A missing piece of the jigsaw in interpreter-mediated medical consultation models.
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In 2015, at the International Conference on Communication in Healthcare in New Orleans, USA, we formed a symposium panel to discuss and debate how interdisciplinary research can inform interpreter-mediated medical consultation training. In all our work, a recurring theme is not just the strengths but also the shortcomings of the guidelines proposed in the textbooks and widely used in medical education. This paper is an account of our multidisciplinary reflections on a prominent issue of the lack of attention to  in communications, which shed light on the limitations of these guidelines and clinical communication models. We propose that an international network be established for all stakeholders to foster interprofessional and interdisciplinary collaboration for research and clinical interventions, and to inform training and policy making.
Krystallidou, Demi (2016). Investigating the interpreter’s role(s): the A.R.T. framework
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Although the interpreter’s function in interaction has attracted significant interest in the literature, the focus is often restricted to verbal interaction alone. This paper introduces an analytical framework, based on Goffman’s construct of role, to examine how participants’ actions: (i) carry communicative meaning that complements their use of language; ii) are interdependent with those of other participants. The analysis also takes into account the normative frameworks which, to a certain extent, shape the interpreter’s and the doctor’s actions. Transcribed excerpts of two authentic medical consultations are examined, along with video stills. The recordings, with interpreting between Dutch and Russian, were made at a Belgian hospital; informed consent and ethical approval were obtained. It is shown that interpreters’ use of non-verbal resources can favour the patient’s inclusion in interaction when s/he is bypassed by the doctor, possibly interested in involving only the interpreter and in leaving little, if any, opportunity for the patient’s voice to be heard.
Krystallidou, Demi; Salaets, Heidi (2016). On interprofessionality in interpreter training: A few thoughts and two stories.
Krystallidou, Demi (2014). Gaze and body orientation as an apparatus for patient inclusion into/exclusion from a patient-centred framework of communication.
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Dialogue interpreter training has traditionally focused on the way in which the interpreter manages, and maintains, verbal interaction between the primary participants while it seems to overlook the importance of specific non-verbal aspects that are inherent in mediated interaction. This article presents an alternative method for the training of medical interpreters by drawing on research on non-verbal communication in interpreter-mediated consultations with a view to drawing attention to the interpreter’s impact on the patient’s inclusion in a patient-centred framework during mediated consultations. More specifically, it provides evidence of non-verbal interaction that might open up new trajectories in the interpreters’ training by foregrounding the impact of the interpreter’s and others’ direction of gaze and body orientation on the accomplishment and maintenance – or lack thereof – of a patient-centred framework of communication. The present article reports on findings that emerged from the analysis of selected excerpts of authentic interpreter-mediated consultations within the framework of a training experiment. Coded instances of interaction are analysed by relying on Goffman’s ‘ratification process’, Goodwin’s ‘participation and engagement frameworks’ and Norris’ ‘modal density foreground–background continuum’. Hospital ethical approval and participants’ written informed consent were obtained prior to the collection of data.
Krystallidou, Demi (2012). On mediating agents’ moves and how they might affect patient-centredness in mediated medical consultations.
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The present study aims to shed some light on indicators that might potentially challenge patient-centredness (as practised by self-professed patient-centred doctors) within a mediated medical encounter, and to contribute to the fields of linguistics, translation studies and medical communication. Selected instances of transcribed video recordings are analysed within the framework of Goffman’s footing and participation roles, while transcribed audio recorded interviews with participants in the triad are taken into consideration as well. Both verbal and non-verbal cues (i.e., gaze) are taken into account. The data is drawn from a corpus of video-recorded mediated consultations in a urban hospital in Belgium. Hospital ethical approval and subjects’ written informed consent have been obtained
Krystallidou, Demi (2020). Going video: Understanding interpreter-mediated clinical communication through the video lens.
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Most of the research on dialogue interpreting has been conducted by taking only verbal interaction into account. Although the existing research has managed to shed some light on the complexity of interpreter-mediated interaction, there is still a lot to be unravelled by adopting a multimodal stance and including non-verbal cues in the analysis of verbal interaction. This study builds on the findings of recent research by Davitti (2013); Davitti & Pasquandrea (2017); Krystallidou (2013, 2014, 2016); Pasquandrea (2011, 2012). In this study, I draw on data taken from a corpus of authentic video-recorded interpreter-mediated consultations at a large urban hospital in Belgium. By applying multimodal analysis to data and comparing it to analysis based on transcripts alone, I highlight a set of interactional dynamics that touch upon new aspects of the complexity of interpreter-mediated interaction and which a transcript-based analysis alone would have failed to capture. It will be shown that participants’ gaze, gestures and body orientation, along with verbal interaction, are used by the interpreter as semiotic resources that do affect the doctor’s and the patient’s participation in interaction. However, the weight the interpreter seems to attach to the primary participants’ semiotic resources seems to be subject to the participation status of each participant.
Krystallidou, Demi (2017). Non-verbals in dialogue interpreter education: Improving student interpreters’ visual literacy and raising awareness of its impact on interpreting performance.
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Dialogue interpreter education has paid little attention to the importance of non-verbal clues in interaction. This paper reports on an experiment at Ghent University where student interpreters were asked to perform a set of activities aiming at raising awareness of the importance of non-verbal behaviour for the co-construction of meaning in interpreter-mediated interaction. At the end of the experiment the students reported that they had become more aware of the impact of their own and others’ non-verbal clues in the co-construction of meaning during interaction.
White, SJ., Barello, S., Cao di San Marco, E., Colombo, C., Eeckman, E., Gilligan, C., Graffigna, G., Jirasevijinda, T., Mosconi, P., Mullan, M., Rehman, SU., Rubinelli, S., Vegni, E., Krystallidou, D. (2021). Critical observations on and suggested ways forward for healthcare communication during COVID-19: pEACH position paper
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Communication in healthcare has influenced and been influenced by the COVID-19 pandemic. In this position paper, we share observations based on the latest available evidence and experiential knowledge that have emerged during the pandemic, with a specific focus on policy and practice. This is a position paper that presents observations relating to policy and practice in communication in healthcare related to COVID-19. Through our critical observations as experts in the field of healthcare communication, we share our stance how healthcare communication has occured during the pandemic and suggest possible ways of improving policy and professional practice. We make recommendations for policy makers, healthcare providers, and communication experts while also highlighting areas that merit further investigation regarding healthcare communication in times of healthcare crises. We have witnessed an upheaval of healthcare practice and the development of policy on-the-run. To ensure that policy and practice are evidence-based, person-centred, more inclusive and equitable, we advocate for critical reflection on this symbiotic relationship between COVID-19 and the central role of communication in healthcare. This paper provides a summary of the key areas for development in communication in healthcare during COVID-19. It offers recommendations for improvement and a call to review policies and practice to build resilience and inclusive and equitable responsiveness in communication in healthcare.





Practice implications