1. Introduction 

Martin (2014) highlighted the interest pragmatics has taken in medical discourse drawing back to 1981 when the Journal of Pragmatics published a volume on the theme: 

Introducing the 1981 special issue of the Journal of Pragmatics on therapeutic discourse, the editors, Haberland and Mey (1981: 105), explain the theme of the volume: “what goes wrong in doctor–patient communication, and what is language’s role in all of this”. Over thirty years later, pragmatics continues to shed light on this knotty relationship and on the intricate choreographies characterizing medical encounters. (2014: 515) 

Medical communication, as any communication, confines to norms which may vary cross-culturally. Scholars have focused on oral doctor-patient communication, with (or without) body movement (Pendleton and Hasler 1983, Heath 1986, Von Raffler-Engel 1989) in monolingual research. The aim was to examine how the interaction may be structured for improving it. Locher and Schnurr (2017) outline the diversity the field of health and communication displays: 

[T]he combination of health and communication is a vibrant research field with a long tradition […]. Many different research disciplines contribute to this field from social psychology, communication studies, health literacy, medical sociology, medical anthropology, education, pragmatics and applied linguistics. The object of study is equally diverse including different interactions between different combinations of interactants (healthcare provider–healthcare provider, healthcare provider–patient, patient–patient, carers–patients, etc.), ideologies and discourses around health and different modes and interaction and their combinations (face-to-face, telephone, leaflets, case reports, e-health contexts, etc.). (2017: 690) 

The present study adds translation to the interdisciplinary complex. Norms of doctor-patient interaction are likely to vary cross-culturally and a relatively safe way of examining cross-cultural variation in it may be through translation practice. 

Translation practice is a field where intercultural variation in medical communication may be spotted and researched. When marketing goals are involved, variation in medical communication may be highly indicative of the norms and tendencies the genre uses cross-culturally. This study investigates medical discourse which appears in leaflets issued by the ‘Hygeia’ private hospital, in Athens, advertising services the hospital offers, in Greek and English, for various conditions, and inform patients or a general unspecialized audience about a medical conditions, potential medication or cure.  

The material seems valuable because it reflects language patterns associated with established patterns of communication and perhaps different social roles cross-culturally. In reviewing psycho- vs. socio-linguistics theories applied to marketing research, Alcántara-Pilar et al. (2017) suggest that the identity speakers want to establish and the relationship with the addressee they want to construct may change when changing language, because of potentially different social codes: 

the speaker’s choice of language in a given situation is shaped by the identity they wish to convey and the relationship they wish to create with the recipients of the message, bearing in mind the contextual aspects of the situation in which they are speaking and the associated social codes. The choice an individual makes to speak a particular language with which to communicate brings with it the choice of a social identity and a sense of belonging to a specific community. By changing the language, the speaker seeks to achieve a series of pre-established objectives, based on the interpretation that recipients make of the message. (2017: 14) 

A pilot investigation of the ‘Hygeia’ private hospital leaflets manifests variation in interpersonal communication (between doctors and potential patients), when the language changes. The study raises awareness of established discoursal patterns in the two cultural environments, hoping to facilitate doctor-patient communication across Greek and English, and eliminate potential risk of misunderstanding and unnecessary emotional burden.   

2. Literature review: On power 

In his theory of power, Foucault (2006), claims that there is no such thing as “pure equality” in communication, even though most of our models of understanding communication make this assumption. Hierarchy in social relationships is always present, however subtle. In every culture, there are always some groups that have more privileges in communication, in the terms of social hierarchy, such as higher prestige or status. Foucault’s main interest lies in the question where power is ‘located’ in culture; who does and who does not have it; how power is distributed; how it is maintained. He argues that power is dynamic, flowing through individuals in various contexts and relationships.  

The research uses cultural dimensions and communication styles (Hofstede, Hofstede and Minkov 2010) which affect intercultural communication, namely, power distance, a dimension of culture which concerns the extent to which the less powerful members of a culture expect and accept that power, prestige, and wealth are distributed unequally. 

In contexts where the level of power distance seems to be higher, chances are that children would obey their parents, and people are expected to display respect for those of higher status. For instance, in countries such as Cambodia, Laos, and Thailand, people are expected to display respect for monks by ritualistic greetings, making gestures like removing hats in the presence of a monk, dressing modestly, seating monks at a higher level, and using language that shows respect. Contexts with high power distance favour the concentration of power in the hands of those of higher status, rather than distributed equally among all the social layers. These countries tend to be stricter and they may communicate in a more authoritarian way, as they underpin the inequalities between interpersonal relations. 

High- and low- power distance parallels the interpersonal distance/proximity of the im/politeness framework (Brown and Levinson 1978, Bousfield and Locher 2008), which acknowledges performance of FTAs (Face Threatening Acts) intentionally or unintentionally. Researching threat in interaction, intra- or inter- culturally, is highly fruitful in that threat may occur (even unintentionally), if addressee expectations are not met. For instance, if speakers used interpersonal proximity in a high-power context, they would end up rising threat awareness in their interlocutors, which may hinder communication goals. Alternatively, high-power distance communication in low context environments may sound at least awkward, if not impolite. 

In an attempt to elaborate on power distance, Hofstede et al. (2010) suggest certain criteria which seem to affect power distance: 1. Geographic Latitude. In this case, the correlation is inversely proportional. Lower latitudes are associated with higher power distance. 2. Population. In countries with large populations the level of power distance is higher. 3. Wealth. Cultures known for their wealth tend to appear lower power distance. 4. History. Countries with a Romance language (Spanish, Portuguese, Italian, French) score medium to high, as do Confucian cultural inheritance countries. Contexts with a Germanic language (German, English, Dutch, Danish, Norwegian, Swedish) score low. Both the Romance language contexts and the Confucian cultural inheritance ones were ruled from a single power center, whereas the Germanic language countries remained “barbaric” during Roman days. This study refers to communities of practice, like practices in medical advertising, rather than whole cultures, as suggested in Hofstede et al. (2010). 

Hofstede et al.’s (2010) dimensions interrelate with each other. Contexts with low levels of power distance, display high levels of individualism, and low levels of masculinity have higher social and institutional capacity (Husted 2005). In New Zealand, characterized as a low power distance culture, it is common for subordinates to address managers by their first name; in Hong Kong, high in power distance, people of lower rank in the workplace usually address those of higher rank with titles to preserve hierarchical relationships. 

Greek is a positive politeness language (Sifianou 1992) displaying high levels of collectivism in interaction, but certain contexts favour interpersonal distance and unequal distribution of power like negative politeness contexts do (Brown and Levinson 1978), as the present data set will display. In Brown and Levinson’s framework (1978), there are some acts that may provoke threat to another person's face; an insult or expression of disapproval seem to be such acts.  

Threat theory, advanced by Walter et al. (1999), identifies four domains of threat: realistic, symbolic, negative stereotypes, and intergroup anxiety. Realistic threat concerns threat to the political and economic power and well-being of the ingroup. Symbolic threat concerns group differences in values, beliefs, morals, and attitudes, which may lead to prejudice against members of outgroups. Negative stereotypes serve as a basis for negative expectations concerning the behaviour of members of the stereotyped group. The fourth type of threat, intergroup anxiety, refers to people’s feeling of being personally threatened in intergroup interactions, such as being embarrassed, rejected, or ridiculed. The type of threat assumed in this study is the symbolic one, deriving from group differences in values, beliefs, morals, and attitudes. In a Greek to English translation direction, if the Greek audience appreciates high power distance in a medical context, the English version would have to regulate certain points which may be threatening for the English audience, if it is a low-power distance one.  

3. Methodology 

As suggested, this study uses naturalistic data from 20 leaflets (see Appendix 1) of ‘Hygeia’ private hospital, Athens, in order to investigate threat manipulation in medical discourse cross-culturally (c. 8,000 words per language version). The study juxtaposed the two versions, spotted pragmatic variation in the hospital-audience communication and categorized it, highlighting variation occurring between the two versions. Threat awareness considerations and power distance between expert-patient were two features which seemed to stand out when analyzing the two versions of the data set.  

The etic perspective to the data was followed by an emic perspective, namely, consideration of lay people’s view with respect to the above phenomena. The study designed a questionnaire addressing 20 bilingual postgraduate students with an acute perception of what linguistic variation may pragmatically signify. The questionnaire (see appendix 2) used some of the examples which the study analyzed and elicited data which verified etic findings. 

4. Data analysis 

The section identifies instances, in the medical leaflets, which show that the English version attempts to minimize threat which would have been produced, if the Greek had been transferred literally in English. A second section of Data analysis deals with the manipulation of interpersonal distance/proximity, which the two versions adjust to meet the expectations of the respective contexts. 

4.1 Threat awareness  

The subsection shows that the English version of the medical data set is very much concerned about minimizing threat in the communication with the patient. The Greek version is more tolerant to threat but raises the level of formality to compensate for it. 

Example 1 

Τhe very term condition translating πάθηση (=disease) carries lower emotional burden than that of πάθηση. It is as if medical texts in Greek prefer to highlight risk in order to persuade audience to check their health. The use of your in English assumes interpersonal proximity, which balances the impact of a potential threat. The results of the questionnaire show that the 98 percent of the participants agree that the Greek version carries higher threat awareness.  

Example 2 

Nominalizations (για την ενίσχυση) raise the level of formality and heighten power distance between interlocutors. By contrast, in English, the verbal structure (to compliment) has a lowering effect on power distance. Also, offered signals an attempt of the English text to decrease the psychological burden of the programme by making it by making it seem as an offer, which encourages expert-patient communication.  

Example 3 

In example 3, the English version is more encouraging in that it decreases the possibility that a surgery may be necessary, with the adverbial only in severe cases. In Greek, the threat is higher with no attempt at mitigation, because the adverbial [σ]ε βαριές περιπτώσεις (in severe cases), being at sentence initial position, holds within its scope the potential for a surgery. 

4.2 Power distance 

The subsection shows that, contrary to the positive politeness character of Greek in interaction which would favour interpersonal proximity, the medical genre favours interpersonal distance (high power distance, where inequality in society is accepted). Likewise, contrary to the negative politeness character of English in interaction which would normally favour interpersonal distance, the English version favours low power distance and interpersonal proximity. 

Example 4 

In Greek, the doctor’s specialty (rheumatologist) assumes higher complexity with reference to the condition, which is more threatening. This is avoided in the English version with the general item Doctors. The appearance of the binary rheumatologist-patient in the Greek version also highlights the power differentials between the persons involved. Furthermore, the use of the adjective your in English emphasizes interpersonal proximity (vs. a definite article in Greek). 95 percent of the (Greek) questionnaire respondents suggested that the Greek version creates a higher sentiment of trust, evidently acknowledging the higher power distance between doctor-patient in the Greek version, and the respect to doctors, as high prestige personalities. 

Example 5 

In example 4, the use of the imperative in English (i.e., find a way) is more encouraging and expects the patients to act on their own. 80 percent of the questionnaire respondents suggested the connotation holds in English. By contrast, the Greek text implies a strong trust to the doctor, who has the responsibility and the power to act. The Greek text display higher power distance between doctor-patient. Besides, the use of your 

Example 6 

Here, is another example of the use of the adjective your, in English. It marks a lower level of power distance by directly communicating with the client-patient. Hence, the use of the imperative mode in English (vs. the nominalization in Greek) which implies that the patients should act on their own. Questionnaire respondents verified the active role assumed of the English patient by 100 percent. 

Example 7 

The impersonalized structure in Greek (is necessary) raises the level of formality and makes the doctor seems to be more important and dominant in the Greek text, with 80 percent of the questionnaire participants being in agreement.  

Example 8 

In example 8, the role of the specialist is empowered as manifested through μπορούμε να ελέγξουμε (we can control: power distance and collectivism), whereas in the English version the role of the specialist is less powerful and assisted by technology.  

Example 9 

Passivization in Greek, παρατηρείται (is observed) vs. the English active verb allows raises the level of formality and interpersonal distance, creating a high-power distance context of situation.  

5. Discussion 

Corporations contact their target groups through advertising and the “cognitive and emotional response of the consumers are established through those advertisement messages” (Aktan and Ozupek 2017: 424). As language constructs social relations, it seems highly important for research to study discourses, in order to decipher the specifics of corporate communication with clients. In this study, the medical advertising campaign seems to be aware of the shift in power dynamics in medical contexts, across English and Greek.  

The study selected 20 medical leaflets of the ‘Hygeia’ Hospital, Athens, and contrasted the Greek and English versions, with respect to implied pragmatic meaning. It focused on relational dynamics, namely threat awareness and how it may be tolerated in the English and Greek community of practice. Results showed that manipulation of threat and the fear of performing a Face-Threatening Act changed the power distance dynamics cross-culturally.  

The study verifies the importance of genre in discourse. As suggested, Greek is a positively polite language in interaction (Sifianou 1992), with English being a negatively polite language (Brown and Levinson 1978). This may also be manifested through translation for the stage (Sidiropoulou 2012, 2021) where oral speech is involved. However, in medical discourse the tendencies seem reversed: Greek favours interpersonal distance, as the data showed, and English rather favoured interpersonal proximity.  

Table 1. Genre and pragmatic meaning in translation.  

Malamatidou (2016) examined Greek target versions of English popular science articles from Popular Science and Scientific American and found a high preference for passivization and interpersonal distance in Greek – which however is reduced over the years because of a code-copying mechanism which operates in Greek, because of the high inflow of English translated discourse into the country. In examining English-Greek political science translation, Sidiropoulou (2017) found that the relational dynamics (proximity/distance) between political scientist and reader are highly important in reshaping the relationship in the Greek target version, with the Greek target version heightening distance (as in Table 1[b}). 

6. Conclusions and significance of the research  

Translation is a rich resource for tracing discoursal tendencies cross-culturally, where genre, the role of participants and the relation dynamics between interlocutors are highly important. Dayter et al. (2023) suggest that mediality (the medium), participation structure (the role of participants in the communicative situation) and their relational dynamics between interlocutors are ‘promising loci’ of pragmatic research on translational data. In alignment with this theoretical perspective, the study examined the specifics of medical print advertising, and the relational dynamics between the hospital/expert and potential patients.  

The study contributes to a more nuanced understanding of cultural diversity and shows that cultural values operate as cultural repertoires of behaviours (Liu et al. 2014) in social life.  The manipulation of threat in medical discourse varied cross-culturally. 

As expected, medical texts give evidence concerning the treatment of FTAs cross culturally. Greek tolerates greater threat and perhaps uses formality to compensate for it, the implication being: it is not necessarily about you, this is what the science suggests, in these conditions. By contrast, the English version attempts to minimize any threatening implications. It is evident that the target text (English) uses items of lower emotional load, that appears to be more reassuring. 

The results of this study may be used in order to facilitate the communication in medical context cross culturally; it goes without saying that awareness of pragmatic differences in the communication with a patient, would make cross-cultural understanding easier to achieve. 

 Analyzing pragmatics in medical contexts is rather uncharted territory. Communication with a medical institution or an expert is a significant practice and a worth-examining one. The study analyzed medical discourse in print. More channels of medical communication would be worth-investigating, such as hospital talk and medical interpreting (de Souza and Fragkou 2020). 

References 

Aktan, Ercan, and Mehmet Nejat Ozupek (2017) “Corporate Advertising at the Age of Social Media” in Advertising and Branding: Concepts, Methodologies, Tools, and Applications vol.1, Information Resources Management Association (ed), Hershey PA, IGI Global: 413-429. 

Alcántara-Pilar, Juan Miguel, Salvador del Barrio-García, Esmeralda Crespo-Almendros, and Lucia Porcu (2017) “A Review of Psycho- vs. Socio-linguistics Theories: An Application to Marketing Research” in Advertising and Branding: Concepts, Methodologies, Tools, and Applications vol.1, Information Resources Management Association (ed), Hershey PA, IGI Global: 1-30. 

Bousfield, Derek, and Myriam A. Locher (2008) Impoliteness in Language: Studies on its Interplay with Power in Theory and Practice, Berlin, Mouton de Gruyter. 

Brown, Penelope, Stephen C. Levinson (1978) Politeness. Some Universals in Language Usage, Cambridge, Cambridge University Press. 

Dayter, Daria, Miriam A. Locher and Thomas C. Messerli (2023) Pragmatics in Translation –Mediality, Participation and Relational Work. Cambridge, Cambridge University Press. 

de V. Souza, Izabel E.T., and Effrossyni Fragkou (eds) (2020) Handbook of Research on Medical Interpreting, IGI Global, Harshey, PA, USA.  

Foucault, Michel (2006) History of Madness. Transl. Jean Khalfa. New York, Routledge. 

Heath, Christian (1986/2006) Body Movement and Speech in Medical Interaction, Cambridge, Cambridge University Press. 

Hofstede, Geert, Gert Jan Hofstede, and Michael Minkov. (2010) Cultures and Organizations: Software of the Mind, New York, McGraw-Hill. 

Husted, Bryan W. (2005) “Culture and Ecology: A Cross-National Study of the Determinants of Environmental Sustainability”, Management International Review 45: 349–71. 

Locher, Miriam A., and Stephanie Schnurr (2017) “(Im)politeness in Health Settings”, in The Palgrave Handbook of Linguistic (Im)politeness, Jonathan Culpeper, Michael Haugh, Dániel Z. Kádár (eds), London, Palgrave Macmillan: 689-711. 

Liu, Shuang, Zala Volčič, and Cynthia Gallois (2014) Introducing Intercultural Communication: Global Cultures and Contexts, Thousand Oaks, CA, Sage Publications. 

Malamatidou, Sofia (2016) “Understanding Translation as a Site of Language Contact: The Potential of the Code-Copying Framework as a Descriptive Mechanism in Translation Studies”, Target 28, no. 3: 399-423. 

Martin, Gillian (2014) “Pragmatics and Medical Discourse” in Pragmatics of Discourse, Klaus P. Schneider and Anne Barron (eds), Berlin/Boston, Walter de Gruyter: 491-524. 

Pendleton, David, and John Hasler (1983) Doctor-patient Communication, United Kingdom, Academic Press. 

Sidiropoulou, Maria (2017) “Politeness Shifts in English-Greek Political Science Discourse: Translation as a Language Change Situation”, Journal of Politeness Research 13, no. 2: 313–343. 

Von Raffler-Engel, Walburga (ed.) (1989) Doctor-patient Interaction, Amsterdam, John Benjamins. 

Walter, Stephan, G., Oscar Ybarra, and Guy Bachman (1999) “Prejudice toward Immigrants”, Journal of Applied Social Psychology 29, nο. 11: 2221-37. 

Appendix 1

Data Sources: Greek-English ‘Hygeia’ Hospital leaflets, Athens