Transcript Language Barriers in Health Care

Overcoming Linguistic
Barriers in Health Care
Challenges, Current Practices, and
Directions for the Future
Number of Patients Needing Interpreter
Services
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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:
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LEP patients…
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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
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Title VI of The Civil Rights Act (1964)
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Requires all federally funded health care facilities
to provide access to interpreters
Informed Consent
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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
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“It costs too much money”
“It takes too much time”
Jacobs 2007; Fagan 2003
The Costs of Interpreter Services
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Cost varies between institutions
Some studies have reported costs:
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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
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Fewer tests ordered
Increased use of preventative services and
primary care
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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
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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
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Mixed data on how patients feel about this
method
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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
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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
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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
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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
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Patients are generally very satisfied with this
method, while providers are not
Patients value:
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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
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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
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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
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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 Englishspeaking counterparts
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Not just language barriers – ?may also need to improve
health care literacy
Too few language concordant physicians to rely on
them alone
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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?
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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
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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