Information is property of the National Center for Cultural Competence, Georgetown University Center for Child & Human Development
Interpretation Services
Although the health and mental health care workforce is diversifying in the number of workers who are multicultural and multilingual, this is not occurring rapidly enough to respond to the need in the patient population. Health and mental health care organizations are responding to this dilemma by using interpreters, both trained and untrained, and contracting with other technology-based language support, such as interpretation by telephone or video (Internet) based. The following is an analysis of current trends in the provision of interpretation services.
Untrained interpreters. A vast majority of health care organizations and professionals are using two types of untrained interpreters: family and friends of the patient and bilingual staff. Although it is against federal regulations to ask patients to supply their own interpreters, many organizations and professionals are unaware of or unclear about these regulations. In many instances, organizations use untrained bilingual or multilingual staff (may be referred to as heritage speakers—those who learned a language at home and/or in the community and may not be trained in medical or other interpretation, see http://hablamosjuntos.org/is/index.asp). These staff include receptionists, dietary workers, janitors, and clerks who perform interpretation on an ad hoc basis. Typically, organizations justify such practices by citing lack of skilled staff and resources and by having an attitude that this is the best that can be provided under the circumstances.
Organizations also hire bilingual or multilingual medical or clinical assistants who are expected to perform interpretation as one aspect of their duties; these are often called dual-role interpreters. Many dual-role interpreters are hired into entry-level positions that may or may not require a high school education. Their language abilities may be assessed only superficially or not at all.
There are numerous problems with using untrained interpreters. These problems have been documented in the use of family and friends, ad hoc interpreters, and dual-role interpreters. The potential for miscommunication, medical errors, and possible liability problems is significant when such untrained persons are used (Baker, Parker, Williams, Coates, & Pitkin, 1996; Flores et al., 2003; Rivadeneyra, Elderkin-Thompson, Silver, & Waitzkin, 2000). Quality of care is distinctly impeded. Unless the provider is somewhat versed in the patient’s language, it can be very difficult to determine where errors in communication are occurring. For information on “Special Problems in the Use of Family, Friends, and Minors as Interpreters in Health Care Settings” and “Pitfalls in the Use of Untrained Interpreters,” see Section D.
Trained or Certified Interpreters. The use of professionally trained interpreters is considered best practice and can improve the quality of care to patients with limited English proficiency (Jacobs et al., 2001; Lears & Abbott, 2005; Rhodes, 2000; Oquendo, 1996). Although national certification for medical interpreters is still not available, standards for quality medical interpretation have been developed in California by the California Healthcare Interpreters Association (CHIA) http://www.chia.ws, and in Massachusetts by the Massachusetts Medical Interpreters Association (MMIA) http://www.mmia.org. Further, an assessment guide has been developed by the National Council on Interpreting in Health Care (NCIHC) http://www.ncihc.orgrecommending that interpreters be assessed in the following areas:
- Basic language skills in the two languages,
- Ethics and ethical decision making,
- Cultural issues,
- Health care terminology,
- Integrated interpreting skills, and
- Written translation of simple instructions.
The NCIHC, a national organization for health care interpreters, lists on its Web site 18 state associations for health care interpreters. Many of these state organizations offer training sessions, instructional meetings, and yearly conferences. Health care organizations interested in improving the language proficiency and interpreter skills of its bilingual and multilingual interpreting workforce can encourage and financially support their personnel to participate in these organizations where available.
As mentioned above, Hablamos Juntos is providing leadership in the development of promising and evidence-based practices in the field of language access, including interpretation. It offers many resources and strategies for health care organizations seeking to design, maintain, or enhance their interpretation services at http://www.hablamosjuntos.org/is/default.index.asp.
Community interpreter banks can be the most cost-effective way to provide a wide range of languages to a community, by sharing costs among partners, participants, or customers. An interpreter bank can take a variety of forms, including but not limited to: an accessible database of interpreters for a community; a community-based organization that provides the interpreters as needed; or a pool of interpreters shared by community hospitals, clinics, or other organizations with similar language access needs. For examples of such cooperative programs, see the following:
Numerous training opportunities are available for interpreters through organizations and colleges. One example is Cross Cultural Health Care, which offers medical interpretation training and other key resources at http://www.xculture.org/training/index.html. To link directly to the well-known training program “Bridging the Gap,” see http://www.xculture.org/training/overview/interpreter/programs.html.
There are also widely used publications such as: Language Barriers in Health Care Settings, Health Care Interpreter Training in the State of California, and How to Choose a Language Agency, funded by The California Endowment (see http://www.calendow.org, Publications section, Cultural Competency category); Providing Language Interpretation Services in Health Care Settings: Examples from the Field, funded by The Commonwealth Fund, see http://www.cmwf.org.
Provider barriers. Data show that even when interpreters are available, health care professionals underused their services for a variety of reasons, including cost, time, and lack of knowledge of how to work effectively with interpreters. Even in situations in which providers recognize that failing to use available interpreters may result in suboptimal care, they may attempt communication in a language in which they are not proficient, or use family members including children, or prevail on their proficient colleagues, or avoid communication entirely with patients who have limited English proficiency (Burbano O’Leary, Federico, & Hampers, 2003; Hornberger, Itakura, and Wilson, 1997). Studies have shown conflicting data with respect to whether encounters in which interpreters are used are actually more time consuming, but data consistently show that the use of interpreters improves care for this patient population.
Hablamos Juntos published a report in 2004 with findings from focus groups conducted with physicians who treat persons with limited English proficiency. The executive summary and full report can be downloaded from http://www.hablamosjuntos.org/physicians/.
In a study by Karliner, Perez-Stable, and Gildengorin (2004), health care providers were asked about their most recent patient encounter that involved an interpreter. Fewer than half of the respondents were “satisfied with their ability to empower the patient with knowledge about their disease, treatment or medication” (Abstract); although most reported satisfaction with the medical care they provided in that encounter, they reported difficulties in eliciting exact symptoms (71%), explaining treatments (44%), and eliciting treatment preferences (51%). Providers who had previous training in working with interpreters were more likely to use interpreters and more likely to be satisfied with the medical care they provided. This study strongly suggests that health care organizations have not systematically addressed language access in policy, procedures, and practices.
A number of medical and nursing schools include instructions and practice in the use of interpreters in their curricula. This has, however, been a recent development, and many practicing health care professionals have not had the benefits of such training. One training organization, the Cross-Cultural Health Care Program in Seattle, www.xculture.org, offers such a program called “Communicating Effectively Through an Interpreter.” Another resource developed by Mutha, Allen, and Welch, at the Center for the Health Professions, University of California, San Francisco, includes a section on the role of the medical interpreter and specific tools, strategies, and exercises for working with interpreters. See http://www.futurehealth.ucsf.edu/cnetwork/resources/curricula/diversity.html. For guidelines on using interpreters, see the Resources section.
Telephonic or other technology-based interpreting. The use of telephones and other media has emerged as a method of providing interpretation services. Interpretation can be provided when the patient and provider are together in one room, or telephone calls between patient and provider can be patched into the telephonic interpreter. Advice nurses and call centers can also patch into these services. When a provider initiates a request for an interpreter with the telephonic dispatcher, a medical interpreter speaking the requested language is usually available within 1 minute.
Telephonic services do not take the place of face-to-face interpreting, but they are critical linguistic aids when health care organizations do not have access to interpreters who speak a rare or uncommonly needed language. They are also useful to specialty practices that have a low volume of referrals.
Other technology-based interpreting includes video interpreting and voice over Internet protocol. For information, see https://www.fedvrs.us/help/about.asp and http://www.fcc.gov/voip/. The Registry of Interpreters for the Deaf developed standards on interpreting for a range of contexts, including medical settings (http://www.rid.org/118.pdf) and mental health settings (http://www.rid.org/126.pdf).
Federal laws and guidelines related to language access
The following is a selected list of the federal laws and guidelines related to language access, including their related Web sites:
The U.S. Department of Health and Human Services issued these guidelines for organizations that are in any part funded by federal monies. A number of states have followed suit with legislation or contract language requiring that linguistic services be provided to patients with limited English proficiency in state- supported health and mental health care programs. These federal and state regulations have been compiled by the National Health Law Program and are updated regularly at http://www.healthlaw.org/langaccess/index.shtml. Additional information is available from NCCC’s Policy Brief 2, Linguistic Competence in Primary Health Care Delivery Systems: Implications for Policy Makers (Goode, Sockalingam, Brown, & Jones, 2000, revised 2003), at http://gucchd.georgetown/nccc/documents /Policy Brief 2 2003.pdf
