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All-domain complexity in video remote interpreting in maternity care

A NASSS analysis

 | University of Stirling
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Abstract
Inadequate interpreting services contribute to maternal health disparities among women who require support. Video remote interpreting (VRI) has been promoted as a solution, yet its implementation and sustained uptake remain uneven and poorly understood. This study draws on the non-adoption, abandonment, scale-up, spread and sustainability (NASSS) framework to examine the challenges shaping VRI use in the UK National Health Service’s (NHS) maternity care. It analyses a dataset involving women requiring interpreting support and their families, support workers, maternity care professionals, interpreters, bilingual health advocates, language service providers, trainers and a commissioner. The data sources included interviews, surveys, ethnographic observations, a focus group and documentary materials. The qualitative data were analysed using reflexive thematic analysis and were integrated with descriptive statistics across NASSS domains. The analysis shows that the adoption of VRI is shaped by interrelated challenges spanning the NASSS domains, including unpredictable demand, technological constraints, contested value propositions, adopter training challenges and organisational, regulatory and workforce factors. The findings suggest that linguistic diversity functions as a complexity multiplier which amplifies and interconnects implementation challenges across domains, while the effectiveness of VRI depends on the sustainability and governance of the interpreter workforce. These findings highlight the need for ecosystem-level coordination that includes the linguistic, organisational, workforce and technological dimensions of interpreting-assisted maternity care.
Article outline
  • 1.Introduction
  • 2.Methods
    • 2.1NASSS framework
    • 2.2Interpreter-on-wheels (IOW)
    • 2.3Study design and participants
    • 2.4Data analysis
    • 2.5Ethical considerations
  • 3.Findings
    • 3.1Domain 1: The condition
      • 3.1.1Conflicting stakeholder perspectives on language support needs
      • 3.1.2Language documentation practices and mismatches in language provision
    • Domain 2: The technology
      • 3.2.1Reliability and connectivity
      • 3.2.2System design and workflow disruption
      • 3.2.3Training and knowledge requirements
    • 3.3Domain 3: Value proposition
      • 3.3.1Commercial and organisational value logics shaping VRI provision
      • 3.3.2LOTE women’s evaluations of desirability, effectiveness and safety
    • 3.4Domain 4: The adopter system
    • 3.5Domain 5: The organisation
    • 3.6Domain 6: The wider system
    • 3.7Domain 7: Adaptation over time
  • 4.Discussion
    • 4.1Linguistic diversity and cross-domain implementation complexity
    • 4.2Interpreter workforce dependency and implementation sustainability
    • 4.3All-domain complexity in VRI services
    • 4.4Practical and policy implications
  • 5.Conclusion
  • Data availability statement
  • Acknowledgments
  • Note
  • Author queries
  • References
References (43)
References
Abimbola, S., Patel, B., Peiris, D., Patel, A., Harris, M., Usherwood, T. & Greenhalgh, T. (2019). The NASSS framework for ex post theorisation of technology-supported change in healthcare: Worked example of the TORPEDO programme. BMC Medicine 17 (1), 1–17. Google Scholar logo with link to Google Scholar
Angermeyer, P. S. (2008). Creating monolingualism in the multilingual courtroom. Sociolinguistic Studies 2 (3), 385–404. Google Scholar logo with link to Google Scholar
Aquino, M. R. J. V., Edge, D. & Smith, D. M. (2015). Pregnancy as an ideal time for intervention to address the complex needs of Black and Minority Ethnic women: Views of British midwives. Midwifery 31 (3), 373–379. Google Scholar logo with link to Google Scholar
Bancroft, M. A., García-Beyaert, S., Allen, K., Carriero-Contreras, G. & Socarrás-Estrada, D. (Eds). (2015). The community interpreter: An international textbook. Columbia, MD: Culture and Language Press.Google Scholar logo with link to Google Scholar
Braithwaite, J., Churruca, K., Long, J. C., Ellis, L. A. & Herkes, J. (2018). When complexity science meets implementation science: A theoretical and empirical analysis of systems change. BMC Medicine 16 (1), 1–14. Google Scholar logo with link to Google Scholar
Braun, V. & Clarke, V. (2022). Thematic analysis: A practical guide. London: Sage. Google Scholar logo with link to Google Scholar
Bridle, L., Bassett, S. & Silverio, S. A. (2021). “We couldn’t talk to her”: A qualitative exploration of the experiences of UK midwives when navigating women’s care without language. International Journal of Human Rights in Healthcare 14 (4), 359–373. Google Scholar logo with link to Google Scholar
Care Quality Commission. (n.d.). Care Quality Commission: About us. [URL] (accessed 14 Mar 2026).
Casey, E. N., Fitzgerald, E., Rackers, H. S., Bates, D., Fox, K. & Bygd, M. (2025). Descriptive analysis of interpreter service mode costs & usage in northwestern Wisconsin pre and peri COVID-19. BMC Health Services Research 25 (1), 1–10. Google Scholar logo with link to Google Scholar
Cosstick, E., Nirmal, R., Cross-Sudworth, F., Knight, M. & Kenyon, S. (2022). The role of social risk factors and engagement with maternity services in ethnic disparities in maternal mortality: A retrospective case note review. eClinicalMedicine 521, 1–12. Google Scholar logo with link to Google Scholar
Cross–Sudworth, F., Williams, M. & Gardosi, J. (2015). Perinatal deaths of migrant mothers: Adverse outcomes from unrecognised risks and substandard care factors. British Journal of Midwifery 23 (10), 734–740. Google Scholar logo with link to Google Scholar
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A. & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science 4 (1), 1–15. Google Scholar logo with link to Google Scholar
Diamond, L. C., Schenker, Y., Curry, L., Bradley, E. H. & Fernandez, A. (2009). Getting by: Underuse of interpreters by resident physicians. Journal of General Internal Medicine 24 (2), 256–262. Google Scholar logo with link to Google Scholar
Fiedler, J., Pruskil, S., Wiessner, C., Zimmermann, T. & Scherer, M. (2022). Remote interpreting in primary care settings: A feasibility trial in Germany. BMC Health Services Research 22 (1), 1–12. Google Scholar logo with link to Google Scholar
Gilbert, A. S., Croy, S., Hwang, K., LoGiudice, D. & Haralambous, B. (2022). Video remote interpreting for home-based cognitive assessments: Stakeholders’ perspectives. Interpreting 24 (1), 1–27. Google Scholar logo with link to Google Scholar
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly 82 (4), 581–629. Google Scholar logo with link to Google Scholar
Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Fahy, N., Procter, R. & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability of health and care technologies. Journal of Medical Internet Research 19 (11), 1–21. Google Scholar logo with link to Google Scholar
Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Procter, R. & Shaw, S. (2018). Analysing the role of complexity in explaining the fortunes of technology programmes: Empirical application of the NASSS framework. BMC Medicine 16 (1), 1–15. Google Scholar logo with link to Google Scholar
Husain, L. & Greenhalgh, T. (2025). Examining intersectionality and barriers to the uptake of video consultations among older adults from disadvantaged backgrounds with limited English proficiency: Qualitative narrative interview study. Journal of Medical Internet Research 271, 1–16. Google Scholar logo with link to Google Scholar
James, H. M., Papoutsi, C., Wherton, J., Greenhalgh, T. & Shaw, S. E. (2021). Spread, scale-up, and sustainability of video consulting in health care: Systematic review and synthesis guided by the NASSS framework. Journal of Medical Internet Research 23 (1), 1–15. Google Scholar logo with link to Google Scholar
LanguageLine Solutions. (n.d.a). On-demand telephone and video interpreting languages. [URL] (accessed 14 Mar 2026).
. (n.d.b). Earn a certificate of competency in medical interpreting. [URL] (accessed 14 Mar 2026).
Li, L. (2025a). Maternity interpreting in the UK healthcare system: An investigation of access, service provision and video-mediated interpreting with multiple stakeholders. PhD dissertation. University of East Anglia.
(2025b). The vicious circle: How systemic barriers perpetuate maternity interpreting service inadequacies for migrant women in the UK. Frontiers in Global Women’s Health 61, 1–16. Google Scholar logo with link to Google Scholar
Lion, K. C., Brown, J. C., Ebel, B. E., Klein, E. J., Strelitz, B., Gutman, C. K., Hencz, P., Fernandez, J. & Mangione-Smith, R. (2015). Effect of telephone vs video interpretation on parent comprehension, communication, and utilization in the pediatric emergency department: A randomized clinical trial. JAMA Pediatrics 169 (12), 1117–1125. Google Scholar logo with link to Google Scholar
May, C. R., Cummings, A., Girling, M., Bracher, M., Mair, F. S., May, C. M., Murray, E., Myall, M., Rapley, T. & Finch, T. (2018). Using normalization process theory in feasibility studies and process evaluations of complex healthcare interventions: A systematic review. Implementation Science 13 (1), 1–27. Google Scholar logo with link to Google Scholar
May, C. R. & Finch, T. (2009). Implementing, embedding, and integrating practices: An outline of normalization process theory. Sociology 43 (3), 535–554. Google Scholar logo with link to Google Scholar
McLeish, J. & Redshaw, M. (2017). Mothers’ accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: A qualitative study. BMC Pregnancy and Childbirth 17 (1), 1–14. Google Scholar logo with link to Google Scholar
Mertens, D. M. (2003). Mixed methods and the politics of human research: The transformative-emancipatory perspective. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social & behavioral research. Thousand Oaks, CA: Sage, 135–164.Google Scholar logo with link to Google Scholar
(2009). Transformative research and evaluation. New York, NY: Guilford Press.Google Scholar logo with link to Google Scholar
Mottelson, I. N., Sodemann, M. & Nielsen, D. S. (2018). Attitudes to and implementation of video interpretation in a Danish hospital: A cross-sectional study. Scandinavian Journal of Public Health 46 (2), 244–251. Google Scholar logo with link to Google Scholar
Muecke, M. A. (1994). On the evaluation of ethnographies. In J. M. Morse (Ed.), Critical issues in qualitative research methods. Thousand Oaks, CA: Sage, 187–209.Google Scholar logo with link to Google Scholar
NRPSI. (2019). NRPSI annual review of public service interpreting in the UK. [URL] (accessed 14 Mar 2026).
Parsons, J. A., Baker, N. A., Smith-Gorvie, T. & Hudak, P. L. (2014). To ‘get by’ or ‘get help’? A qualitative study of physicians’ challenges and dilemmas when patients have limited English proficiency. BMJ Open 4 (6), 1–9. Google Scholar logo with link to Google Scholar
Plsek, P. E. & Greenhalgh, T. (2001). Complexity science: The challenge of complexity in health care. BMJ 323 (7313), 625–628. Google Scholar logo with link to Google Scholar
Pointon, T. (1996). Telephone interpreting service is available. BMJ 312 (7022), 53. Google Scholar logo with link to Google Scholar
Saeki, S., Iwata, M., Tomizawa, R. & Minamitani, K. (2022). Challenges and the potential of promoting remote medical interpreting during COVID-19. Global Health & Medicine 4 (6), 341–346. Google Scholar logo with link to Google Scholar
Schulz, T. R., Leder, K., Akinci, I. & Biggs, B.-A. (2015). Improvements in patient care: Videoconferencing to improve access to interpreters during clinical consultations for refugee and immigrant patients. Australian Health Review: A Publication of the Australian Hospital Association 39 (4), 395–399. Google Scholar logo with link to Google Scholar
Shaw, S., Wherton, J., Vijayaraghavan, S., Morris, J., Bhattacharya, S., Hanson, P., Campbell-Richards, D., Ramoutar, S., Collard, A., Hodkinson, I. & Greenhalgh, T. (2018). Advantages and limitations of virtual online consultations in a NHS acute trust: The VOCAL mixed-methods study. Southampton: NIHR Journals Library.Google Scholar logo with link to Google Scholar
Stevens, L. A., Mitchell, P. M., Vasquez, J., Lopez, G. M., Gutierrez, A. & McGrath, M. E. (2011). Spanish-speaking patient satisfaction with interpreter services in the emergency department: Comparison of in-person versus live-feed video interpretation. Annals of Emergency Medicine 58 (4s), S308. Google Scholar logo with link to Google Scholar
Tang, D., Jawad, D., Dragoje, V., Wen, L. M. & Taki, S. (2024). The use of interpreter services and its barriers faced by hospital staff when accessing interpreters for patients with low English proficiency during the COVID-19 pandemic. Health Promotion Journal of Australia 35 (4), 1184–1193. Google Scholar logo with link to Google Scholar
Zhang, W., Davitti, E. & Braun, S. (2026). Charting the landscape of remote medical interpreting: An international survey of interpreters working in remote modalities in healthcare services. Perspectives 34 (1), 109–134. Google Scholar logo with link to Google Scholar
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