Osae‑Larbi  SpringerPlus  (2016) 5:900 
DOI 10.1186/s40064‑016‑2602‑x
MEETING REPORT Open Access
Bridging the language barrier gap in the 
health of multicultural societies: report of a 
proposed mobile phone‑based intervention 
using Ghana as an example
Judith Ansaa Osae‑Larbi*
Abstract 
Across the globe, societies are recording an increasing number of domestic and international migrants for numerous 
reasons. While this may promote multiculturalism, new migrants and linguistically minority ethnocultural groups may 
face challenges in fully and equitably participating in various aspects of broader societies, due to language barriers. 
The purpose of this paper is to propose the use of Unstructured Supplementary Service Data (USSD) codes as an 
innovative intervention to address this long standing issue of language barriers, specifically as it pertains to accessing 
pertinent health information in multicultural societies. The USSD is a protocol that allows two‑way communication 
between mobile phones and service providers, and which can be used independent of internet access. By dialing 
specific USSD codes (e.g. *555#) on their mobile phones, the proposed intervention would enable culturally and 
linguistically diverse populations in Ghana to access pertinent health information, particularly preventive information 
in understood language options on their phones. Using the current state of multiculturalism in Ghana as an example, 
this paper also describes how the proposed intervention can be developed, implemented and evaluated. The paper 
concludes by highlighting the significance of the proposed intervention to multiculturalism in Ghana and the impli‑
cations for research. Bridging language barriers in access to health information is central to promoting the health of 
multicultural societies and fostering multicultural relationships. Therefore, overall, it is expected that this paper would 
stimulate thinking and research into innovative approaches that may help to successfully bridge language barriers in 
the area of health of multicultural societies.
Keywords: Multiculturalism, Health, Language barriers, Mobile phone intervention, USSD codes
Background problem has for many years been one, if not the greatest, 
Is there any contemporary society or country in the barrier to effectively accessing and utilizing health infor-
world comprised of a population, where all members are mation and services. This is particularly the case for new 
of the same cultural or ethnic group, speak the same lan- migrants from culturally and linguistically diverse back-
guage, and share a single cultural or civic identity? While grounds (Lee 2003).
the answer may be clear—none—the multicultural state This paper is a further development of a poster presen-
of most contemporary societies readily brings to the tation,1 and seeks to propose the use of Unstructured 
fore, the problem of language barriers and their poten- Supplementary Service Data (USSD) codes as an innova-
tial grave consequences across various sectors of the tive mobile phone-based intervention in response to this 
economy of these societies. In the area of healthcare, this long standing issue of language barriers, as it pertains to 
*Correspondence:  jaosae‑larbi@st.ug.edu.gh 1 Poster presented at the 9th Biennial Conference of the International Acad-
Department of Psychology, School of Social Sciences, College emy for Intercultural Research (IAIR 2015), Bergen, Norway, 29 June–1 July, 
of Humanities, University of Ghana, P. O. Box LG 84, Legon, Accra, Ghana 2015.
© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License 
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, 
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, 
and indicate if changes were made.
Osae‑Larbi  SpringerPlus  (2016) 5:900 Page 2 of 7
accessing pertinent health information in multicultural information, it remains the case that these trained per-
societies. Specifically, the paper presents a brief overview sonnel are woefully scarce in most developing countries 
of the benefits of language bridging in the area of health- like Ghana. This may be due to the huge cost generally 
care; the challenges to using medical interpreters; the role involved in training and hiring interpreters across health-
of technology in language bridging; and the current state care settings (Dowbor et al. 2015). Even in countries with 
of multiculturalism in Ghana. Within this context of mul- multiculturalism polices that foster bilingual competen-
ticulturalism in Ghana, the paper further describes how cies (e.g. Canada) and other developed countries such as 
public health stakeholders and telephone service provid- Australia, the United Kingdom, and the United States, 
ers can collaborate to develop, implement, and evaluate reports indicate a lack of professional interpreters (Dow-
the impact of the proposed intervention on access to per- bor et al. 2015; Lee 2003). These reports further suggest 
tinent (preventive) health information. The paper finally that linguistically minority groups in these countries may 
concludes by highlighting the role of the proposed inter- still face vital challenges to meeting their health infor-
vention in promoting multiculturalism in Ghana and the mation needs due to language barriers. In Ghana, where 
implications for research. Overall, the goal of this paper is trained interpreters may be available, they may be fluent 
to stimulate thinking and research into innovative and only in the languages of neighboring regions or coun-
widely applicable ways of bridging language barriers that tries. Furthermore, they may be primarily based in physi-
affect the health of multicultural societies. cal healthcare and urban settings and almost absent in 
mental healthcare and rural settings. Also, being typically 
Benefits of language bridging in the health of multicultural based in hospitals, medical interpreters may not support 
societies easy access to preventive information among general 
Across the globe, the benefits of removing language populations faced with language barriers. Thus, for coun-
barriers in healthcare cannot be underestimated. Evi- tries like Ghana, where the lack of healthcare resources 
dence indicates that it increases access to healthcare, necessitates primary prevention approaches to promot-
promotes higher quality and safe care, improves patient ing public health, innovative solutions independent of 
satisfaction, enhances appropriate utilization of health- real-time medical interpreters are worth considering.
care resources, and increases preventive health activi-
ties (Jacobs et al. 2004; American Institutes for Research The role of technology in language bridging 
2005; Schyve 2007). Furthermore, improved physical in multicultural societies
and mental health through better access to health infor- Over the years, various technological methods have been 
mation and services typically underpins the day-to-day developed to meet the demand for innovative approaches 
functioning of individuals and whole societies. to the problem of language barriers in access to health-
In some countries such as Canada, medical interpret- care information. The Integrated Healthcare Communica-
ers have been relied on to address the health informa- tor (Cheong 2014) is one such approach. It is believed to 
tion needs of migrants and non-dominant ethnocultural be the first smartphone app to support voice translation 
groups, who face language difficulties in healthcare set- of healthcare instructions from English into a local dia-
tings (Lee 2003). Most studies assessing the benefits of lect (Cantonese). Real-time over-the-phone interpreta-
language bridging in healthcare (e.g. Jacobs et  al. 2004) tion services have also been adopted in certain countries 
have also focused on the effects of interpreter services. like Canada to support patient-provider communica-
Indeed, reviews of such studies have shown that inter- tion in hospitals (Dowbor et  al. 2015). Overall, a review 
preter services improve important outcomes such as of published literature and unpublished data on the use 
patient satisfaction, health care delivery, communication, of language interpretation approaches indicate that tech-
and healthcare utilization (Karliner et  al. 2007; Ramirez nological advances are feasible in improving healthcare 
et  al. 2008). A review by Bauer and Alegría (2010) has communication as well as quality of care for linguistically 
also shown that assessing patients’ mental health status in minority populations (Masland et al. 2010). Unfortunately, 
their non-primary language or using untrained interpret- the typical internet and smartphone-dependent nature 
ers can lead to inaccurate diagnosis. On the other hand, of many of these methods make them less applicable to 
it was found that the use of professional interpreters may developing countries like Ghana. In Ghana, majority of 
improve disclosure in patient-provider communications, residents in the rural areas typically have limited access 
referral to specialty care, and patient satisfaction. to internet and smartphones. Besides, similar to medical 
interpreters, most of these technological approaches can 
Challenges to the use of medical interpreters be used only within healthcare settings, limiting their use 
While evidence supports the use of medical inter- in promoting access to preventive healthcare information 
preters to improve access to and utilization of health among Ghana’s general population.
Osae‑Larbi  SpringerPlus  (2016) 5:900 Page 3 of 7
Indeed, attempts are being made by some telephone ser- multicultural health methods in Ghana, it is not uncom-
vice providers in the country to make health information mon to see instances in hospitals where relatives, health-
economically accessible to customers. Basically, customers care workers, and sometimes other patients are called on 
call their service provider’s health experts at reduced call to serve as lay interpreters for patients facing language 
rates. While this may provide convenient access to health barriers. New migrants may also face significant chal-
information, there are several limitations. First, these ser- lenges in gaining access to pertinent health information 
vices are limited in access to customers of respective ser- (e.g. about vaccinations) needed to protect their health 
vice providers. Even among customers of such telephone and that of natives.
network providers, not all may be aware of these services. The following section duly proposes an innovative 
Also, the health information may generally be provided mobile phone-based strategy in response to the problem 
in English. Further, the content of the information may of language-barriers in accessing vital health information 
be developed without much consideration of the unique in Ghana. The section further discusses how the coun-
health information needs of ethnocultural and migrant try’s multicultural regions/societies can collaborate with 
groups resident in different areas of the country. In effect, service providers to develop, implement, and evaluate the 
there exist a huge public health challenge of poor access to proposed intervention. In the light of Ghana’s new NMP, 
pertinent health information, particularly preventive infor- the proposed approach is indeed, timely for the country.
mation, among migrants, linguistically minority groups, 
and ethnocultural groups residing in Ghana. Proposed intervention in the context 
of multiculturalism in Ghana
Ghana’s context of multiculturalism Intervention description
Ghana is a West African country bounded by three fran- The proposed intervention is the Unstructured Sup-
cophone countries; on the north by Burkina Faso, on the plementary Service Data (USSD) multicultural health 
east by Togo, and on the west by Côte d’Ivoire. Currently, intervention service. The USSD is a protocol used by 
the ten-region country is home to an estimated 75 ethno- cellular phones to communicate with a telecommunica-
cultural/native groups, each speaking at least one distinct tion service provider. A USSD application has a unique 
language, although some languages (e.g. Twi) may be short code in the form of *specific numbers# (e.g. *128#) 
commonly spoken by other cultural groups. Each region or *specific numbers*specific numbers# (e.g. *121*2#). 
of the country is also home to internal migrants from These short codes are dialed and sent to the service 
other regions and international migrants from countries provider’s server using a phone. In response, the phone 
including Mali and China. Demographically, ideologi- receives a message or a menu linked to different messages 
cally, and linguistically therefore, Ghana is a multicultural (from the server). Harnessing this two-way communica-
nation. Yet, despite her rich diversity, Ghana lacks formal tion technology, the proposed intervention would allow 
multicultural policies, practices, and strategies necessary culturally and linguistically diverse groups in the coun-
to ensure that individuals, irrespective of tribe, region, or try to dial specific USSD codes on their phones, receive 
country of origin have equitable rights to participate in, a menu of pertinent health information in response, and 
as well as benefit from the various sectors of the coun- access (read) any information needed, in understood lan-
try’s economy. guage options.
In the area of health, the closest policy is the National Among populations with limited use of smart phones, 
Migration Policy for Ghana (Government of Ghana limited access to the internet, and/or limited access to 
2014), which recommends “the adoption of a framework important resources like banks and health information 
to mitigate potential public health risks from migration, centers such as clinics, the USSD technology has been 
without adversely impacting the positive gains of migra- successfully used to bridge the gap in reaching these pop-
tion.” (GoG 2014, p. 4). Although this policy is a posi- ulations with vital services. Notable among these services 
tive step forward towards the protection of the health of are financial (mobile money) and bill paying services. In 
Ghana’s multicultural societies, practical measures and Uganda, this technology has also been used to success-
strategies are needed to achieve its recommendations. As fully collect health research data among such populations 
emphasized by Sam (2015), multiculturalism transcends (Namugaayi 2014). The use of USSD codes is independ-
the mere presence of diversity and policies. It is in actual ent of internet access, providing a wider reach to popula-
sense, “the existence of, and a policy with its attending tions in rural areas and of all age groups.
practices regarding the living together of, many ethno-
cultural groups in a plural society, as well as the norma- Intervention goal
tive beliefs that characterize how the relationships should The goal of the intervention is to support both local and 
be among the groups.” (Sam 2015, p. 3). In the absence of international ethnocultural groups in Ghana to gain easy 
Osae‑Larbi  SpringerPlus  (2016) 5:900 Page 4 of 7
access to important health information. This includes into (e.g. English, Twi, Ga, Hausa, Ewe, Dagomba, French, 
information that promotes prevention of illnesses (e.g. Swahili, and Mandarin). (2) The agency would set up a 
malaria, cholera, Ebola, meningitis, hepatitis, diabetes, committee in each region that may comprise of physi-
HIV/AIDs), encourages effective utilization of healthcare cal, mental, and public health professionals, social work-
resources and services (e.g. free child immunizations, ers, lay persons from different migrant and ethnocultural 
vaccinations, health screening), and facilitates navigation groups of respective regions, research assistants, and 
of healthcare processes and systems in Ghana (e.g. loca- certified interpreters for each language option. (3) Com-
tion and opening times of both public and private health mittees would diagnose the pertinent general and region-
facilities, available services in respective facilities, contact specific health information needs of ethnocultural groups 
details of physical and mental health centers, standard in Ghana (e.g. vaccination requirements against meningi-
referral procedures to larger hospitals or mental hospi- tis for residents of the Northern regions) as well as collate 
tals, as well as roles and contact details of social work- information on the health resources and services avail-
ers, community and lay healthcare workers, and relevant able in each region using appropriate resources.
non-governmental health support organizations).
Stage two (collaborate)
Intervention stages Here, two major actions may be required based on the 
To achieve the above goal, it is proposed that a four-stage understanding gained from the first stage. (1) Commit-
nonlinear model (hereafter, the Multicultural Health tees would develop content of the pertinent health infor-
Information Model, MHIM) is used to guide the devel- mation to meet the health general and region-specific 
opment and implementation of the USSD multicultural health needs of ethnocultural groups. (2) Committees 
health information service. These stages are the “Under- across the ten regions would work together to review 
stand”, “Collaborate”, “Innovate”, and “Evaluate” stages. and group information content in all languages and for 
The MHIM was developed from prominent organiza- each region into concise message sections that would be 
tional change models including the Three-Step model of appropriately grouped under standard themes. Standard 
change (Lewin 1947); the eight-stage Action Research themes may serve as the menu from which specific infor-
model (Lewin 1946); and the four-stage General Model of mation (sections) may be accessed. Here, any unique cul-
Planned Change (Cummings and Worley 2009). All three tural values of the populations that speak the languages 
models generally direct change agents to first diagnose or included in the multicultural health information service 
reach detailed Understanding of the problem in need of may be considered, for instance in how the information 
change; collaborate with organizational members to plan content may be presented or worded.
and develop the intervention (Collaborate); implement 
the intervention (Innovate), and Evaluate any changes Stage three (innovate)
resulting from the intervention. Evidence supports Here the committees would work with all telecommuni-
the effectiveness of these models in guiding successful cation service providers in Ghana to (1) Assign specific 
planned changes in organizations and whole systems, USSD codes to main health information menu options. 
including medical/healthcare systems (Asumeng and (2) Assign navigation numbers to the different sections of 
Osae-Larbi 2015; Cummings and Worley 2009; Gallos information under each menu option. (3) Decide on the 
2006). Therefore, the MHIM, which is a comprehensive content of an automated prompt call and/or text message 
yet concise model from these tested models, may help to to be sent to all phones connected to a service provider 
better promote efforts of Ghana’s public health system, in Ghana, as a strategy to raise and increase awareness 
specifically with regards to reaching culturally and lin- of the proposed health information service. Prompt call 
guistically diverse groups of people with critical health messages would be repeated in all language options. 
information. At each stage of the model, the following (4) Decide on the times/frequency of disseminating the 
key actions may be necessary to bring about successful prompt message (e.g. at first connection of any phone 
implementation of the USSD multicultural health infor- to the server of any service provider in the country and 
mation service. every quarter to existing phone users). After completion 
of this stage, phone users can access pertinent health 
Stage one (understand) information in understood language options.
At this preparatory and evidence gathering stage, three 
actions may be required. (1) The sponsoring (public Stage four (evaluate)
health) agency overseeing the project such as the Ghana The committees may decide on appropriate evaluation 
Health Service would determine the different languages study designs at this stage or the first preparatory stage. 
that the health information may need to be translated Pre- and post-intervention (with control) data among 
Osae‑Larbi  SpringerPlus ( 2016) 5:900 Page 5 of 7
linguistically diverse cultural groups across the regions and how accessing a piece of health information may play 
may be collected to ascertain the effects of this inno- out on a mobile phone.
vation on level of access to key health information as a 
primary outcome. The influence of this innovation on Discussion
physical and mental health status may also be assessed This paper has proposed an innovative mobile phone-
as long term outcomes in longitudinal study designs. based technology—USSD codes—as a strategy to bridge 
Based on findings from the evaluation, committees can the language barrier gap in accessing vital health infor-
make appropriate revisions to actions taken at any of the mation in multicultural societies. Using Ghana’s context 
preceding stages, as well as update content of the USSD of multiculturalism as an example, this paper has also 
multicultural health information service, in line with the described how relevant stakeholders can collaborate 
non-linear nature of the MHIM. Figure  1 illustrates the to develop, implement, and evaluate the impact of this 
proposed stages for the development of the intervention phone-based intervention on important public health 
Fig. 1 Proposed intervention development stages and example flow chart of the USSD multicultural health information service intervention. 
Beginning with the Understand stage, the intervention can be developed in four main stages that are non‑linear, allowing intervention developers 
to revise the key actions that may be taken at any of the stages. The intervention will allow phone users to access pertinent health information on 
their phones by dialing a specific USSD code and following the navigation instructions to access the needed information in an understood lan‑
guage option. 1Prompt call message would be repeated in all the language options. Prompt (text) messages may be sent when user misses prompt 
call
Osae‑Larbi  SpringerPlus  (2016) 5:900 Page 6 of 7
outcomes. Further, it has brought to the fore, the need Conclusion and implications for research
for Ghana and similar societies to move beyond cul- In conclusion, language barriers may compromise the 
tural diversity and establish policies, programmes, and health of multicultural societies through poor access to 
practices that promote equitable access to health infor- pertinent preventive health information and its related 
mation. It is expected that successful development and poor access to quality healthcare services. Thus, all efforts 
implementation of the proposed language-bridging to test the effectiveness and feasibility of the proposed 
intervention would (1) improve easy access to well- language-bridging strategy, particularly in plural societies 
understood critical health information for linguisti- that lack multicultural health policies and programmes, are 
cally diverse cultural groups across Ghana; (2) promote worth considering. It is imperative that longitudinal study 
the health of multicultural societies over time; and (3) designs are adopted to ascertain the long term impact of 
inform successful ways of facilitating multiculturalism the proposed intervention on the health of migrant and 
beyond the area of health, considering the centrality of ethnocultural groups, as well as the feasibility of the MHIM 
effective two-way communication to all human interac- in guiding development and implementation of the inter-
tions and institutions, particularly where cultural diver- vention. Also, research that examines the impact of an 
sity is concerned. extended version of the intervention, where the interven-
Overall, it is expected that this intervention would tion content can be accessed as automated voice messages 
help to foster multiculturalism in Ghana in a number of by dialing short codes on mobile phones, may support spe-
ways. First, successful implementation of this multilin- cial groups such as the visually impaired and those inca-
gual health information service may promote a sense of pable of reading, to access key health information. Finally, 
belonging to the wider Ghanaian society among cultur- future research that considers the benefits of “global inte-
ally diverse groups, while indicating acceptance of the gration” as associated with the concept of omniculturalism, 
unique cultural and linguistic identities of these groups. compared to the sociocultural integration of multicultural-
Evidence of the effectiveness of the intervention (from ism needs to be championed and any necessary revisions to 
the evaluation stage) may also encourage establishment the proposed intervention, duly effected.
of programmes to bridge language barriers in other 
aspects of Ghana’s economy. This may in turn, facilitate Competing interestsThe author declares that she has no competing interests.
equitable participation of diverse cultural groups in the 
respective aspects of the country’s economy. Further-
more, resources that may have been used to manage Received: 16 November 2015   Accepted: 16 June 2016
health complications that may arise from poor access to 
preventive health information (due to language barri-
ers), may be channeled into developing and improving References
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