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

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: 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 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 “It costs too much money” “It takes too much time”

Jacobs 2007; Fagan 2003

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 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 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 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 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 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 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 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 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?

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 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