In-person Interpreters Research Articles

Developmental Screening of Refugees: A Qualitative Study.

Refugee children are at high developmental risk due to dislocation and deprivation. Standardized developmental screening in this diverse population is challenging. We used the Health Belief Model to guide key-informant interviews and focus groups with medical interpreters, health care providers, community collaborators, and refugee parents to explore key elements needed for developmental screening. Cultural and community-specific values and practices related to child development and barriers and facilitators to screening were examined. We conducted 19 interviews and 2 focus groups involving 16 Bhutanese-Nepali, Burmese, Iraqi, and Somali participants, 7 community collaborators, and 6 providers from the Center for Refugee Health in Rochester, New York. Subjects were identified through purposive sampling until data saturation. Interviews were recorded, coded, and analyzed using a qualitative framework technique. Twenty-one themes in 4 domains were identified: values/beliefs about development/disability, practices around development/disability, the refugee experience, and feedback specific to the Parents' Evaluation of Developmental Status screen. Most participants denied a word for "development" in their primary language and reported limited awareness of developmental milestones. Concern was unlikely unless speech or behavior problems were present. Physical disabilities were recognized but not seen as problematic. Perceived barriers to identification of delays included limited education, poor healthcare knowledge, language, and traditional healing practices. Facilitators included community navigators, trust in health care providers, in-person interpretation, visual supports, and education about child development. Refugee perspectives on child development may influence a parent's recognition of and response to developmental concerns. Despite challenges, standardized screening was supported.

Understanding Refugees’ Perceptions of Health Care in the United States

Ongoing conflicts around the world have resulted in record numbers of refugees. Given the unique health care needs and access barriers refugees face upon resettlement in the United States, we aimed to better understand refugees’ perceptions of US health care as the first step to quality improvement initiatives. We used a qualitative approach by conducting 4 focus group interviews with refugees from Iraq, Eritrea, Somalia, and Bhutan. We identified 3 common themes: conflicting expectations, miscommunication, and varying levels of trust and satisfaction. Findings support in-person interpreters, cultural competency training, and integrated primary health care delivery models with stronger connections with resettlement agencies.

Evaluation of a quality improvement intervention to increase use of telephonic interpretation.

Language barriers are associated with poor health care outcomes, and barriers exist for timely in-person interpretation. Although available on-demand, telephonic interpretation remains underutilized. This study evaluates whether a quality improvement (QI) intervention was associated with rates of interpretation and parent-reported language service use at a children's hospital. The QI intervention was developed by a multidisciplinary team and included provider education, electronic alerts, standardized dual-handset telephones, and 1-touch dialing in all hospital rooms. Interpreter use was tracked for 12 months before, 5 months during, and 12 months after the intervention. Weekly rates of interpretation per limited English proficient (LEP) patient-day were evaluated by using segmented linear regression. LEP parents were surveyed about professional interpretation and delays in care. Responses before, during, and after the intervention were compared by using the χ(2) test for trend. Telephonic interpretation rates increased by 53% after the intervention (baseline 0.38 per patient-day, increased 0.20 [0.13-0.28]). Overall (telephonic and in-person) interpretation increased by 54% (baseline 0.96, increased by 0.51 [0.38-0.64]). Parent-reported interpreter use improved, including more frequent use of professional interpreters (53.3% before, 71.8% during, 69.3% after, P trend = .001), less frequent use of ad hoc interpreters (52.4% before, 38.1% during, 41.4% after, P trend = .03), and fewer interpretation-related delays in care (13.3% before, 7.9% during, 6.0% after, P trend = .01). This QI intervention was associated with increased telephonic interpreter use and improved parent-reported use of professional language services. This is a promising approach to deliver safe, timely, and equitable care for the growing population of LEP children and families.

Household and individual risk factors for anemia in children in East Africa

obtaining an appropriate interpreter. Many of the adult participants preferred an internet-based video interpreting service over in-person interpreters because of increased dialect options, as well as shorter wait times. Although traditional medicines and healing techniques were used in refugee camps and occasionally in Indianapolis, most Burmese place trust with western medicine and report valuing and complying with physician recommendations. Many have a basic understanding of good health practices and the causes of illness. This is seen most consistently in the adolescent groups. Interpretation: Overall, Burmese Chin have adapted to their new home. Although they experience common frustrations with the healthcare system, these frustrations were exacerbated by long waits for an interpreter. Resources, such as a phone or video-based interpreter, are available in most health care facilities and preferred by the Burmese. More research is needed to better understand the challenges of the Burmese population residing in the United States. Funding: AAP Resident CATCH Grant: McHenry Abstract #: 02SEDH025

Suggestions for strategies when communicating via in-person interpreters: A qualitative study on communication within home care services in Sweden

The aim of this study was to explore and suggest strategies for communicating via in-person interpreters, based on experiences of professional home care providers (i.e. nurses and nurse assistants) and social workers. Home care services with its multifaceted emphasis on physical, psychological, social aspects of care and focus on quality of life for the patients presents a challenge for successful interpreted communication as the communication have to cover a wide variety of topics. Previous studies have shown that non-medical issues tend to be less communicated about when using interpreters. The study has an interpretative design, and data were collected in seven focus groups interviews with registered nurses, assistant nurses and social workers in home care services. Data were analysed by means of inductive content analysis. The results reveal suggestions for strategies: making preparations for structure and transparency, creating a flowing conversation on multifaceted topics, forming an understanding of the patient’s voice and limiting the information content. This study concludes that the home care providers and social workers need to be prepared for communication via an interpreter about complex phenomena, that communicating information via an interpreter requires preparation prior to the meeting, as well as being an active part in the conversation. Infrequent use of professional interpreters could threaten the possibilities for care providers and social workers to communicate with linguistic diverse patients in an optimal way.

Communication through in‐person interpreters: a qualitative study of home care providers' and social workers' views

To describe the experiences of home care providers and social workers in communication, via in-person interpreters, with patients who do not share a common language, and to offer suggestions for practice based on this description. The use of interpreters is essential for successful communication to provide equal access to health care for patients not sharing a common language with care providers. Successful bilingual communication is probably even more complex within the home care services with its focus on medical treatment, care and daily support in relation to the more exclusive focus on medical treatment within hospital care. An explorative, qualitative, descriptive study. Data were collected in seven focus group interviews. A total of 27 persons, working as registered nurses, assistant nurses and social workers in municipal home care, participated. The analysis was inspired by inductive content analysis. The results express a traditional view on interpretation where the in-person interpreter is supposed to act to a greater or lesser extent as an objective and neutral conduit or communicator of what is said. The interpreter is also expected to observe when medical terms and other concepts need to be explained, which thus exceeds the basic role as a communicator of what was said. This study emphasises the need to view the interpreter as an active and explicit party in a three-way communication. Viewing the interpreter as an active and explicit party in a three-way communication and as an essential part of the care team might reduce the possible threat to patient confidentiality, and could contribute to solve the problem of interpreting the patient's non-verbal signs.

State Policies and Language Access in California’s HMOs: Public Reporting and Regulation of HMOs’ Language Services

Describe the status of language access services for California's limited English proficient (LEP) health maintenance organization (HMO) members within the context of voluntary public reporting and anticipated state regulation. Descriptive analysis of longitudinal data provided by health plans. Retrospective, descriptive analysis of responses to voluntary annual/biennial surveys of commercial, Medicare, Medicaid, and Healthy Families HMOs, 2003-2008. From 2003 to 2008, during California's public reporting of HMO language services, the percentage of HMOs providing in-person interpretation free of charge to consumers increased to over 80% across all product lines. By 2008, the percentage of commercial HMO plans matching new LEP members to providers by language increased to 70%, while 79% provided telephone interpretation services in at least seven languages. Increasingly HMOs provide language access services for LEP Californians, perhaps resulting from public reporting and anticipated state regulation, although similar trends in other states cannot be ruled out.

Impact of an Easy-Access Telephonic Interpreter Program in the Acute Care Setting: An Evaluation of a Quality Improvement Intervention

Language barriers render interaction with the health care system difficult and lead to health disparities for patients with limited English proficiency (LEP). Despite a long-standing legal obligation for large health care organizations in the United States to try to provide free language access services for patients with LEP, professional interpretation is not always widely accessible, and even when it is, its use is often suboptimal. A dual-handset phone with 24-hour access to professional telephonic interpretation was placed at the bedside of all patients admitted to the general medicine floor of a tertiary care academic hospital. Nurses and physicians were surveyed before and after the easy-access interpretation program's implementation. Distribution of pre- and postimplementation surveys to 127 and 122 nurses, respectively, yielded a total of 163 completed surveys (overall participation rate, 65%). Distribution of surveys to 96 and 78 physicians, respectively, yielded 116 completed surveys (overall participation rate, 67%). After implementation, use of professional telephonic interpreters for communication with LEP patients increased fourfold, without a decrease in use of professional in-person interpreters. There were significant increases in professional interpreter use during brief communications with high error potential, including medication administration (odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.1-3.2) and pre-rounding (OR = 3.4, 95% CI 1.2-9.8). Increasing ease of access to dual-handset interpreter telephones promotes use of professional interpreters in the acute care setting. Future hospital policy should focus on further integrating language services into the hospital environment, accompanied by an educational program to assist in shifting professional norms toward use of professional interpreters.

385 Emergency Department Staff Attitudes and Satisfaction With Live-Feed Video Interpreting for Limited English Proficient Patients: Pre- and Post- Training

385 Emergency Department Staff Attitudes and Satisfaction With Live-Feed Video Interpreting for Limited English Proficient Patients: Pre- and Post- Training

384 Spanish-Speaking Patient Satisfaction With Interpreter Services in the Emergency Department: Comparison of In-Person versus Live-Feed Video Interpretation

The purpose of this study was to compare limited English proficient Spanish-speaking patient satisfaction with professional in-person versus live-feed video interpreters in the emergency department (ED).

Comparison of Throughput Times for Limited English Proficiency Patient Visits in the Emergency Department Between Different Interpreter Modalities

Appropriate interpretation is imperative for families with limited English proficiency (LEP). We compared throughput times for ED visits involving families with LEP based on type of interpretation provided: in-person interpretation, remote telephonic interpretation or bilingual providers. This study is a secondary analysis of a prospective study of caretaker satisfaction with different interpreter modalities. We queried the medical record for event time stamps, clinical factors and disposition. The in-person cohort (116 min) had a significantly shorter total throughput time than telephonic (141 min) and bilingual provider (153 min) cohorts (P < 0.0001), due to a difference in time seen by provider to disposition. Time seen by provider to disposition remained statistically significantly shorter for the in-person cohort when compared to telephonic interpretation when controlling for potential confounders such as admission rate (P = 0.006). In-person interpretation significantly decreased ED throughput times and may be an important consideration in the choice of interpreter modality.

Examining Effectiveness of Medical Interpreters in Emergency Departments for Spanish-Speaking Patients With Limited English Proficiency: Results of a Randomized Controlled Trial

This study examines whether availability of in-person professional interpreter services during emergency department (ED) visits affects satisfaction of limited English proficient patients and their health providers, using a randomized controlled trial. We randomized time blocks during which in-person professional interpreters were available to Spanish-speaking patients in the EDs of 2 central New Jersey hospitals. We assessed the intervention's effects on patient and provider satisfaction through a multilevel regression model that accounted for the nesting of patients within time blocks and controlled for the patient's age and sex, hospital, and when the visit occurred (weekday or weekend). During the 7-month intake period, 242 patients were enrolled during 101 treatment time blocks and 205 patients were enrolled during 100 control time blocks. Regression-adjusted results indicate that 96% of treatment group patients were "very satisfied" (on a 5-point Likert scale) with their ability to communicate during the visit compared with 24% of control group patients (odds ratio=72; 95% confidence interval 31 to 167). (Among control group members who were not very satisfied, responses ranged from "very dissatisfied" to "somewhat satisfied.") Similarly, physicians, triage nurses, and discharge nurses were more likely to be very satisfied with communication during treatment time blocks than during control time blocks. We did not assess acuity of illness or global measures of satisfaction. Use of in-person, professionally trained medical interpreters significantly increases Spanish-speaking limited English proficient patients' and their health providers' satisfaction with communication during ED visits.

Interpreters: Telephonic, In-Person Interpretation and Bilingual Providers

Language barriers affect health care interactions. Large, randomized studies of the relative efficacy of interpreter modalities have not been conducted. To compare the efficacy of telephonic and in-person medical interpretation to visits with verified bilingual physicians. This was a prospective, randomized trial. The setting was an urban pediatric emergency department at which approximately 20% of visits are by families with limited English proficiency. The participants were families who responded affirmatively when asked at triage if they would prefer to communicate in Spanish. Randomization of each visit was to (1) remote telephonic interpretation via a double handset in the examination room, (2) an in-person emergency department-dedicated medical interpreter, or (3) a verified bilingual physician. Interviews were conducted after each visit. The primary outcome was a blinded determination of concordance between the caregivers' description of their child's diagnosis with the physician's stated discharge diagnosis. Secondary outcomes were qualitative measures of effectiveness of communication and satisfaction. Verified bilingual providers were the gold standard for noninferiority comparisons. A total of 1201 families were enrolled: 407 were randomly assigned to telephonic interpretation and 377 to in-person interpretation, and 417 were interviewed by a bilingual physician. Concordance between the diagnosis in the medical record and diagnosis reported by the family was not different between the 3 groups (telephonic: 95.1%; in-person: 95.5%; bilingual: 95.4%). The in-person-interpreter cohort scored the quality and satisfaction with their visit worse than both the bilingual and telephonic cohorts (P < .001). Those in the bilingual-provider cohort were less satisfied with their language service than those in the in-person and telephonic cohorts (P < .001). Using the bilingual provider as a gold standard, noninferiority was demonstrated for both interpreter modalities (telephonic and in-person) for quality and satisfaction of the visit. Both telephonic and in-person interpretation resulted in similar concordance in understanding of discharge diagnosis compared with bilingual providers. In general, noninferiority was also seen on qualitative measures, although there was a trend favoring telephonic over in-person interpretation.

Clinician Ratings of Interpreter Mediated Visits in Underserved Primary Care Settings with Ad hoc, In-person Professional, and Video Conferencing Modes

Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).

Comparing In-Person, Video, and Telephonic Medical Interpretation

Using trained interpreters to provide medical interpretation services is superior to services provided on an ad hoc basis, but little is known about the effectiveness of providing their services remotely, especially using video. To compare remote medical interpretation services by trained interpreters via telephone and videoconference to those provided in-person. Quasi-randomized control study. Two hundred and forty-one Spanish speaking patient volunteers, twenty-four health providers, and seven interpreters. Patients, providers and interpreters each independently completed scales evaluating the quality of clinical encounters and, optionally, made free text comments. Interviews were conducted with 23 of the providers, the seven interpreters, and a subset of 30 patients. Time data were collected. Encounters with in-person interpretation were rated significantly higher by providers and interpreters, while patients rated all methods the same. There were no significant differences in provider and interpreter ratings of remote methods. Provider and interpreter comments on scales and interview data support the higher in-person ratings, but they also showed a distinct preference for video over the phone. Phone interviews were significantly shorter than in-person. Patients rated interpretation services highly no matter how they were provided but experienced only the method employed at the time of the encounter. Providers and interpreters were exposed to all three methods, were more critical of remote methods, and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raise questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel, but other factors might have affected time results. Since the patient population studied was Hispanic and predominantly female care must be taken in generalizing these results to other populations.

Improving Patient-Provider Communication

Patients who are communication impaired are at greater risk of medical error and poorer outcomes. Contributing factors that perpetuate ineffective patient-provider communication include the lack of a systematic method for nursing assessment, evaluation, and monitoring of patient-provider communication needs and interventions; and a lack of standardized training of health care providers. We propose a call to action for nursing administrators to position patient-provider communication as a patient safety-care quality priority within the healthcare organization and incorporate bedside practices that achieve effective patient communication, especially with those most vulnerable to impaired communication. Effective patient-provider communication is an essential component of patient care; and in order for communication to be effective, the information must be complete, accurate, timely, unambiguous, and understood by the patient (1). By formally implementing the assessment of patient communication needs into routine care, nursing administrators will create a sense of accountability among bedside nurses to meet the needs of patients who are communication-vulnerable. A patient's right to effective patient-provider communication is supported by accreditation standards (2), regulatory guidelines (3, 4), and patient rights declarations (5, 6). Patients have the right to be informed about the care they receive, make educated decisions about their care, and have the right to be listened to by their providers. However, patient communication needs often go unmet or are addressed inappropriately (7-10). In the case of non-English speaking patients, language access services such as the provision of in-person, telephone, or video interpreters and translated documents are either not available or infrequently used (8-11). Many health care institutions rely on ad hoc interpreters such as family, friends, or administrative and custodial staff to communicate and facilitate patient-provider communication, despite the fact that research has shown that the use of ad hoc interpreters can lead to miscommunication and medical errors (12). For critically-ill or nonspeaking patients, nonverbal behaviors, such as mouthing words, gestures, and head nods, are the principal means of communication; however these methods have been shown to be ineffective, fatiguing and inciting frustration (13-18). Often communication is attempted by simply asking yes/no questions and more appropriate communication interventions are not employed. Limiting the patient's communication to yes/no answers restricts the patient's responses to predictable messages only or messages that meet the a priori expectation of the patient's need as determined by the clinician. The absence of effective patient-provider communication has been cited as a significant factor contributing to adverse outcomes (19, 20). In a 2007 public policy paper focused on health literacy, The Joint Commission recommended that health care organizations “make effective communication an organizational priority to protect the safety of patients” and to “incorporate strategies to address patient's communication needs across the continuum of care” (21). Effective patient-provider communication is a vital component of this transformation and must be prioritized to improve patient safety.

Challenges in Language Services: Identifying and Responding to Patients’ Needs

Identify characteristics of hospital-based language services (LS), and describe practices of identifying patients with limited English proficiency (LEP) and interpreter training. Participants Seventy-one hospitals applied to participate in a national initiative. Applicants were non-federal, acute care hospitals with substantial LEP populations, at least 10,000 discharges, and in-person interpreters. Descriptive statistics were generated on language, collection of language data, LEP volume and service utilization, staffing and training requirements and organizational structure. The relationship between admissions and encounters was analyzed. Ninety percent of hospitals collect primary language data. Spanish is the most common language (93% of hospitals). We found no statistically significant correlation between admissions and encounters. Eighty-four percent require training. Eighty-nine percent have a designated LS department but no clear organizational home. Hospital-based LS programs are facing challenges identifying patients with language needs, staffing and training a workforce, and creating an organizational identity. Need is not associated with utilization, suggesting that LS are not reaching patients.

Language Barriers to Prescriptions for Patients With Limited English Proficiency: A Survey of Pharmacies

Twenty-three million Americans have limited English proficiency. Language barriers can have major adverse consequences in health care, but little is known about whether pharmacies provide adequate care to patients with limited English proficiency. We sought to evaluate pharmacies' ability to provide non-English-language prescription labels, information packets, and verbal communication, and assess pharmacies' satisfaction with communication with patients who have limited English proficiency. We used a cross-sectional, mixed-methods survey of Milwaukee County, Wisconsin, pharmacies. Survey questions addressed sociodemographic and language-service characteristics of pharmacies. A pharmacist or technician at each pharmacy was asked 45 questions by telephone, fax, or mail. The main outcome measures were the ability of pharmacies to provide non-English-language prescription labels, information packets, and verbal communication; and pharmacy satisfaction with communication with patients who have limited English proficiency. Of 175 pharmacies, 73% responded. Forty-seven percent of the pharmacies never/only sometimes can print non-English-language prescription labels, 54% never/only sometimes can prepare non-English-language information packets, and 64% never/only sometimes can verbally communicate in non-English languages. Eleven percent use patients' family members/friends to interpret. Only 55% were satisfied with their communication with patients who have limited English proficiency. In multivariate analyses, community pharmacies had significantly lower odds of being able to verbally communicate in non-English languages, whereas pharmacies using telephone interpreting services had significantly higher odds. Pharmacies' suggestions for improving patient communication included continuing education, producing a chain-wide list of resources, hiring bilingual staff, using telephone interpreters, analyzing translation quality/accuracy of labels and information packets, and adding more languages to pharmacy software. Approximately half of Milwaukee pharmacies never/only sometimes can provide non-English-language prescription labels or information packets, and approximately two thirds never/only sometimes can verbally communicate in non-English languages. One in 9 pharmacies that verbally communicate in non-English languages use patients' family members/friends to interpret. Almost half of the pharmacies are dissatisfied with their communication with patients who have limited English proficiency. Community pharmacies are less likely and pharmacies using telephone interpreting services are more likely to be able to verbally communicate in non-English languages. Study findings indicate that improvements in pharmacies' communication with patients who have limited English proficiency may result by increasing the quality and number of non-English languages in existing computer programs, hiring bilingual staff, and using telephone interpreting services when in-person interpreters are unavailable.

The Interpreter as Cultural Educator of Residents

To determine whether augmentation of the Spanish interpreter's role to include cultural education of residents can improve the satisfaction of Latino patients. We assessed parent satisfaction during 4 sequential 2-month periods between June 1, 2004, and February 11, 2005, using different interpretation methods: telephone interpretation (n = 91 patient encounters), trained in-person interpretation (n = 49), in-person interpretation with cultural education of residents (n = 65), and postprogram telephone interpretation (n = 45). General pediatric practice at a large teaching hospital. A total of 250 Spanish-speaking parents who were limited in English proficiency. The cultural education program included 3 brief preclinic conferences taught by an interpreter and one-on-one teaching of residents about language and cultural issues after each clinical encounter. Parent satisfaction was assessed using 8 questions that have previously been validated in Spanish. Lower scores indicated more satisfaction. Because they were limited in English proficiency, our Spanish-speaking patients were significantly more satisfied when an in-person interpreter was used compared with a telephone interpreter (mean total satisfaction score of 14.5 [in-person] vs 17.4 [telephone]; P = .006) but were even more satisfied when the interpreter educated residents in cultural and language issues (mean, 11.5 [in-person with education] vs 17.4 [telephone]; P<.001). Although use of an in-person interpreter can increase Latino parents' satisfaction, a program using an interpreter to educate residents in cultural and language issues can increase satisfaction further.