Overcoming linguistic barriers in health care
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Overcoming Linguistic Barriers in Health Care. Challenges, Current Practices, and Directions for the Future. Number of Patients Needing Interpreter Services. 2000 census: >46 million people in the US reported English was not their primary language

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Overcoming linguistic barriers in health care

Overcoming Linguistic Barriers in Health Care

Challenges, Current Practices, and Directions for the Future


Number of patients needing interpreter services
Number of Patients Needing Interpreter Services

  • 2000 census: >46 million people in the US reported English was not their primary language

  • Nearly ½ of these (21 million) reported speaking English less than “very well”

US Census Bureau


Effects of limited english proficiency lep on health care
Effects of Limited English Proficiency (LEP) on Health Care:

  • LEP patients…

    • Access preventative and primary care services less frequently

    • Are more likely to be non-adherent

    • Are more likely to be dissatisfied with their care

    • Are more likely to use the ED for primary care

    • Are more likely to be confused about their medications

Wilson 2005; Galbraith 2008


Interpreter services and legal issues
Interpreter Services and Legal Issues

  • Title VI of The Civil Rights Act (1964)

    • Requires all federally funded health care facilities to provide access to interpreters

  • Informed Consent

    • Requires ensuring patient understands diagnosis, treatment options, risks and benefits of treatments, risks of not treating

    • Sometimes done without trained interpreter

    • Often patient asked to sign English consent form

US Dept of Justice; Zabar 2006; Hunt 2007


Common reasons given for not using interpreter services
Common Reasons Given for Not Using Interpreter Services

  • “It costs too much money”

  • “It takes too much time”

Jacobs 2007; Fagan 2003


The costs of interpreter services
The Costs of Interpreter Services

  • Cost varies between institutions

  • Some studies have reported costs:

    • Cost of outpatient interpreter services averaged $279 per LEP patient per year

    • Cost of inpatient interpreter services accounted for 1.5% of total cost of patient care

Jacobs 2004; Jacobs 2007


Potential savings by using interpreter services
Potential Savings by Using Interpreter Services

  • Fewer tests ordered

  • Increased use of preventative services and primary care

    • Catching disease earlier may reduce cost of treating it (ex: Colon Cancer)

    • Keeping chronic conditions well-managed may avoid costly complications (ex: amputations in DM)

  • Cheaper to treat simple complaints in an office than in the ED

Jacobs 2004; Jacobs 2007


Effect of interpreter services on time it takes to see patients
Effect of Interpreter Services on Time it Takes to See Patients

  • There is evidence to suggest that use of telephone interpreters or patient-supplied interpreters (family and friends) does increased length of clinic visit, but that use of professional interpreters does not

  • This may be due to increased efficiency of professional interpreters

Fagan 2003


Current interpretation methods telephone interpreters
Current Interpretation Methods: Telephone Interpreters Patients

  • Mixed data on how patients feel about this method

    • Evidence does not suggest that patients are dissatisfied with telephone interpreters, but some may prefer using family and friends

  • The ability to access interpreters for nearly 200 languages 24hrs a day

    • Telephone interpreters will likely continue to play a role in patient care

Kuo 1999; Lee 2002; Language Line Services


Current interpretation methods ad hoc interpreters
Current Interpretation Methods: Ad Hoc Interpreters Patients

  • Includes bilingual hospital or clinic staff, and patient’s family or friends

  • Lack training in interpretation

  • May have limited knowledge of medical vocabulary

  • May have insufficient fluency

  • Use of Ad Hoc interpreters increases interpretation errors

Hunt 2007; Flores 2005


Use of bilingual staff as interpreters
Use of Bilingual Staff as Interpreters Patients

  • Neither providers not patients very satisfied with this method

  • Takes staff member away from other duties, or adds to workload

  • Should have access to at least some interpreter training, and should be compensated for performing this service

  • May be the only option at times

Zabar 2006; Kuo 1999


Use of patient s family friends as interpreters
Use of Patient’s Family/Friends as Interpreters Patients

  • Patients are generally very satisfied with this method, while providers are not

  • Patients value:

    • Familiarity with the interpreter

    • Interpreter of the same gender

    • Availability to help with transportation and scheduling

  • Highlights need for interpretation services at every point in the process of health care delivery

Kuo 1999


Current interpretation methods professional medical interpreters
Current Interpretation Methods: Professional Medical Interpreters

  • Should be used whenever possible

  • Most are highly trained, but there is no uniform certification process as of yet

  • National Board of Certification for Medical Interpreters

    • plans to have nationwide standardized certification program in place by late 2009

    • Written and oral examinations, recertification every 5 years

Jacos 2007; Natl Board of Cert for Med Interp


Language concordant physicians
Language Concordant Physicians Interpreters

  • Eliminates need for 3rd person in physician-patient discussions

  • Associated with better health outcomes

  • However, LEP patients still more likely to report decreased comprehension than their English-speaking counterparts

    • Not just language barriers – ?may also need to improve health care literacy

  • Too few language concordant physicians to rely on them alone

    • Doing so might limit pool of physicians LEP patients can see, perhaps reducing access to care

Jacobs 2007; Wilson 2005


What can be done now
What Can Be Done Now? Interpreters

  • Providers need more training in using the various methods of interpretation effectively

  • Documents (information brochures, informed consent forms) should be translated into Spanish

  • Additional time scheduled for visits where an interpreter is needed

  • Multilingual phone systems

  • And of course...more research into this issue

Zabar 2006; Hunt 2007; Galbraith 2008


References
References Interpreters

  • US Census Bureau. DP-2. Profile of selected social characteristics: 2000. Available at: http://www.census.gov/prod/2003pubs/c2kbr-29.pdf

  • Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of Limited English Proficiency and Physician Language on Health Care Comprehension. J Gen Intern Med. 2005;20:800-806. 

  • Galbraith AA, Semura JI, McAninch-Dake, RJ, Anderson N, Christakis DA. Language Disparities and Timely Care for Children in Managed Care Medicaid. Am J Manag Care. 2008;14(7):417-426.

  • Jacobs EA, Shepard DS, Suaya JA, Stone EL. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. Am J Public Health. 2004;94:866-869.

  • Lee LL, Batal HA, Maselli JH, Kutner JS. Effect of Spanish Interpretation Method on Patient Satisfaction in an Urban Walk-in Clinic. J Gen Intern Med. 2002;17:641-646.

  • Schyve P. Language Differences as a Barrier to Quality and Safety in Health Care: The Joint Commission Perspective. J Gen Intern Med. 2007;22(Suppl 2):360-1.

  • US Department of Justice. Civil Rights Division. Title VI of the Civil RIghts Act of 1964. Available at: http://www.usdoj.gov/crt/cor/coord/titlevi.php

  • Zabar S, Hanley K, Kachur E, Stevens D, et al. "Oh! She Doesn't Speak English!" Assessing Resident Competence in Managing Linguistic and Cultural Barriers. J Gen Intern Med. 2006;21:510-513. 

  • Hunt LM, de Voogd KB. Are Good Intentions Enough?: Informed Consent Without Trained Interpreters. J Gen Intern Med. 2007;22:598-605.

  • Jacobs EA, Sadowski LS, Rathouz PJ. The Impact of an Enhanced Interpreter Service Intervention on Hospital Costs and Patient Satisfaction. J Gen Intern Med. 2007;22(Suppl 2):306-311.

  • Kuo D, Fagan MJ. Satisfaction with Methods of Spanish Interpretation in an Ambulatory Care Clinic. J Gen Intern Med. 1999;14:547-550.

  • Language Line Services. List of Languages. Available at: http://www.languageline.com/page/languages/

  • Flores G. The Impact of Medical Interpreter Services on the Quality of Health Care: A Systemic Review. Med Care Res Rev. 2005;62(3):255-99.

  • The National Board of Certification for Medical Interpreters. http://www.certifiedmedicalinterpreters.org