Overcoming Linguistic Barriers in Health Care

1. Overcoming Linguistic Barriers in Health Care Challenges, Current Practices, and Directions for the Future

2. 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

3. 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

4. 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

5. Common Reasons Given for Not Using Interpreter Services • “It costs too much money” • “It takes too much time” Jacobs 2007; Fagan 2003

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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