Christina Facchina Fluet, MPH, CI, CT October 7, 2007 Boston, MA

1. Interpreter – Provider Partnerships:Why Are They Important?Presentation to theInternational Medical Interpreters Association(IMIA) 2007 Conference Christina Facchina Fluet, MPH, CI, CT October 7, 2007 Boston, MA

2. Welcome and Introductions • Who I am • Who are you? • Foreign language interpreters? • ASL interpreters? • Primary practice = medical settings? • Interpreter service coordinators? • Health care administrators? • Came to interpreting from a health care profession?

3. THE MAKING OF A MEDICAL INTERPRETER

4. Part 1: Ignorance is bliss? • Novice interpreter in medical settings – how did I get there? • What I don’t know, CAN hurt me - and others: • effects of miscommunication, provider perceptions, legal ramifications, my own biases

6. Part 2: Wrong place - wrong skills • Quickly learned that this is bad combination • Lacked conceptual framework to fully understand why I felt - and was - incompetent • Decision: Take a hiatus……

7. Part 3: Let’s try again • That which we resist the most presents the greatest lessons • Consumer as ally, teacher, and colleague • Continuing education: • Medical and interpreting trainings & classes; talk with other interpreters; talk with providers; mentor; read and listen, e.g., the waiting room as teacher

8. Part 4: Success? • Medical interpreting became one of my primary areas of specialty What changed?

9. FOR DISCUSSION: What has been your evolution as a medical interpreter? OR, if you are an administrator, has your view of the value and/or importance of medical interpreter services changed over time?

10. FROM INTERPRETING TO PUBLIC HEALTH …

11. WHAT DO WE KNOW ABOUT THE RELATIONSHIP BETWEEN INTERPRETERS AND HEALTH OUTCOMES?

12. Background - 1 • Dramatic improvements in health outcomes are not shared equally by all Americans, e.g., life expectancy, diabetes, cardiovascular disease, asthma, cancer, HIV/AIDS • Minority Americans fair worse in both health outcomes and access to and utilization of health care services

13. Background - 2 Contributing factors: • Social determinants: education, SES, housing, environmental hazards, occupational hazards, racism • Lack of access to care: uninsurance, underinsurance • Even for those with access (insurance), lower quality of care (disparities) still exists for minorities

14. What other factors contribute to health disparities?

15. Background - 3 • In 1999, Congress commissioned Institute Of Medicine (IOM) to study health disparities among racial/ethnic minority groups • Result: IOM Report and Recommendations, “Unequal Treatment” (see www.nap.edu) • Since then, rich body of work examining health disparities and factors that contribute to them

16. Background – 4 Beyond social determinants and insurance, other factors that play a key role: • Limited English Proficiency (LEP) • Language and cultural concordance between provider and patient • Culturally competent care • Use of professional interpreters

17. FOR DISCUSSION: Why is it important to understand the public health context for interpreter services? • As an interpreter? • As an Interpreter Services Coordinator? • As a Health Care Administrator?

18. Some Possible Reasons: • Understanding the evidence-based relationships between • language • interpreters • health outcomes (health status, chronic disease) • health services (cost, utilization) i.e., understanding the “business case”

19. Some Possible Reasons: • Understanding providers’ and payers’ perspective - speaking their language

20. Some Possible Reasons: • Greater appreciation for what interpreters do and the power they hold in the medical setting • Can you think of others?

21. Adding to the evidence: MGH Language Concordance Project Center for Child and Adolescent Health PolicyMassachusetts General Hospital Funded by the Deborah Noonan Foundation

22. MGH Language Concordance Project OUR INTEREST: The health of Latino children • Poorer overall health status • Higher rates of morbidity • Poorer access to care (e.g., uninsurance, underinsurance) • Higher rates of unmet need • Lower rates of health service utilization (e.g., well child care)

23. MGH Language Concordance Project Research Questions: Is the quality of well child care for Latino children affected by: • language concordance between parent and provider? • use of interpreters? • provider’s self-rated cultural competence?

24. MGH Language Concordance Project Design: Cross-sectional survey of parents (n=462) and pediatricians (n=22) in three culturally diverse urban (Boston) health centers between January 2006-March 2006

25. MGH Language Concordance Project Parent Measures: “Promoting Healthy Development Survey (PHDS)”: • Assesses specific aspects of well-child care outlined by the American Academy of Pediatrics and the Maternal and Child Health Bureau • Measures “quality of care” (QoC) - preventive and developmental care

26. MGH Language Concordance Project Parent Measures:Aspects of well-child care: • anticipatory guidance • parental education • assessment of family psychosocial environment • family-centered care • helpfulness of care

27. MGH Language Concordance Project Provider Measures: Questionnaire based on two field-tested instruments that assess provider self-reported cultural competence: • language skills • experience working w/minority populations • cultural competence training • perceived effectiveness

28. Analysis - 1 • Bivariate: Control variables (parent education, marital status, yrs in US, child’s insurance status, site of care) & main outcome variables (PHDS domain scores); if p< = .10, forced into regression models • T-tests: Differences in mean PHDS scores between language concordant/discordant dyads and users/non-users of interpreters

29. Analysis - 2 • Multivariate: Step-wise forward and backwards multivariate linear regressions, controlling for variables significant in bivariate analysis, and site • Multi-level modeling: Multilevel random intercept models to understand provider characteristics’ effects on quality of care (patient = first level; provider = second level), i.e., how much of variation in QoC measures is due to patient characteristics and how much due to provider characteristics?

30. MGH Language Concordance Project Findings: • Language concordance not significantly associated with any of these PHDS quality of care measures when controlling for SES • Provider self-perceived effectiveness was associated with higher quality scores for family-centered care and helpfulness of care (how content is delivered) • Use of interpreters was significantly associated with assessment of family environment (what content is delivered)

31. Limitations • Small sample size – 22 providers; influenced power of sub-set analysis (multi-level modeling) • Relatively low response rate – 43% of parents (76% - provider) • Study sites part of larger hospital system that has worked to address organizational cultural sensitivity; may dilute effects of provider language ability on QoC • “Interpreter use” measure does not allow us to analyze which aspects of interpreter’s role affect QoC measures

32. MGH Language Concordance Project Implications of Findings: Cultural sensitivity, as measured by providers’ self-perceived effectiveness, can transcend language barriers and be acquired separate from language skills In a similar fashion, medical interpreters provide culturally appropriate access to care that also transcends language barriers between provider and patient – HOW?

33. “Cultural Brokering” “The need for cultural and linguistic competence in health care delivery systems is emerging as a fundamental approach in the goal to eliminate racial and ethnic disparities in health. The concept of cultural brokering is integral to such a system of care.” (National Center for Cultural Competence. Georgetown University Center for Child and Human Development Georgetown University Medical Center, 2004)

34. Who are cultural brokers in thehealth care system? * Diverse group of individuals that ranges from immigrant children to organizational leaders: - outreach and lay worker - peer mentor - community member/pt - health educator - administrative leader - social worker - health care provider - program manager - interpreter - board member - program support personnel

35. What is the role of a cultural broker?* • As intermediary who bridges the cultural gap by communicating cultural differences and similarities between individuals • As mediator and negotiator of complex processes between organizations, governments, communities, interest groups, or countries * National Center for Cultural Competence. Georgetown University Center for Child and Human Development Georgetown University Medical Center (2004)

36. What Does a Cultural Broker Do? • Liaison: Has knowledge of health care system and their cultural group/community – serves as bridge between the two • Cultural guide: has the trust of both communities, so can facilitate organizational/institutional change, community development

37. What Does a Cultural Broker Do? • Mediator: can help establish trust between medical and lay communities and work to resolve conflicts • Change agent: promotes behavioral and environmental changes that lead to improved organizational capacity to effectively meet needs of the community

38. Interpreter as Cultural Broker • Cultural brokering is an essential function of a medical interpreter • In medical settings, we not only broker between the majority and minority cultures, but also between the medical and layperson cultures

39. REMEMBER THIS? The Making of a Medical Interpreter Part 4: Success? . . . . . . What changed?

40. Interpreter As Cultural Broker - 1 • Came to understand that cultural brokering was an essential part of my role as an interpreter

41. Interpreter As Cultural Broker -2 • Developed better cultural brokering skills: • Better understanding of Deaf community, particularly regarding health care system • Better understanding of my own cultural identity and biases • Improved ability to advocate • Improved skills in cross-cultural communication • Better skills in educating/increasing awareness

42. “Interpreters are the most powerful people in a medical conversation.” ~ Head of Interpreting Services at a major private U.S. Hospital, May 1999 (B Davidson, The interpreter as institutional gatekeeper: The social-linguistic role interpreters in Spanish-English medical discourse. Journal of Sociolinguistics, 4 (3), 379-405)

43. FOR DISCUSSION: • Do you think cultural brokering is an essential function of medical interpreters? Why or why not? • Can you think of examples that illustrate how an interpreter functions in this way? • Do you think that acting as a cultural broker may violate your professional Code of Ethics?

44. ACKNOWLEDGMENTS and THANK YOU • Alexy Arauz-Boudreau, MD, MPH, Principal Investigator, Language Concordance Project, Center for Child and Adolescent Health Policy, Massachusetts General Hospital, Harvard Medical School • Diana Mele, MA, LMHC, IC/TC, Associate Professor, Health Services Program, Deaf Studies, Interpreter Training Program, Division of Law, Education, and Social Professions, Northern Essex Community College • Irma Kahle, MJEd, CI, CT, Director, The Mentorship Program, Massachusetts • Maureen Lundergan, NIC, Northern Essex Community College

45. Select References - 1 • Davidson, D. The interpreter as institutional gatekeeper: The social-linguistic role interpreters in Spanish-English medical discourse. Journal of Sociolinguistics, August 2000; 4 (3), 379-405) • Dysart-Gale, D. Communication Models, Professionalism, and the Work of Medical Interpreters, Health Communication, 2005; 17(1):91-103. • Elderkin-Thompson, V, Silver, RC, Waitzkin, H. When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting, Social Science Medicine, 2001; 52(9):1343-58. • Ferguson, W, Candib, L. Culture, Language, and the Doctor-Patient Relationship, Family Medicine 2002; 34(5):353-61.

46. Select References - 2 • Flores, G. The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research Review, 2005; 62(3):255-99. • Green, A, Ngo-Metzger, Q, Legedza, A, Massagli, M, Phillips, R, Iezzoni, L. Interpreter Services, Language Concordance, and Health Care Quality – Experiences of Asian Americans with Limited English Proficiency, Journal of General Internal Medicine, 2005; 20:1050-1056. • Haffner, L. Translation Is Not Enough - Interpreting in a Medical Setting, In Cross-cultural Medicine – A Decade Later [Special Issue]. Western Journal of Medicine, 1992; 157:255-259

47. Select References - 3 • Iezzoni L, O’Day B, Killeen M, Harker, H. Communicating about Health Care: Observations from Persons Who Are Deaf or Hard of Hearing. Annals of Internal Medicine. 2004;140:356-362 • Jacobs, E, Lauderdale, D, Meltzer, D, Shorey, J, Levinson, W, Thisted, R. Impact of interpreter services on delivery of health care to limited-English-proficient patients. Journal of General Internal Medicine. 2001; 16(7):468-474. • Karliner, L, Jacobs, E, Chen, AH, Mutha, S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 2007; 42(2):727-54.

48. This translation remains but an idea of the thing, and not the thing itself. - Samuel Beckett