When: Nov. 14, 2016 - Nov. 18, 2016 |
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credit attribution: The Global Health Delivery Project, GHDonline.org,
Aug 31, 2017.
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Added on 31 Aug 2017
Authors: Thomas K. Bauer MBA, RT®; Reviewed by Isabelle Celentano
Research shows that poor patient-provider communication is the most frequent cause of serious adverse events and contributes to disparities in care.1 According to the Agency for Healthcare Research and Quality, Limited English Proficiency (LEP) patients in the US are more likely to report poor health, decline needed care, leave the hospital against medical advice, miss follow-up appointments, and experience drug complications. Furthermore, language barriers lead to inefficient care when providers are not able to understand their patients’ symptoms, resulting in unnecessary diagnostic tests and procedures, as well as higher rates of misdiagnosis and hospital readmission. Providing culturally and linguistically appropriate health services is essential to delivering equitable care to the growing LEP population.2
Several solutions have been examined, but more work is needed to understand how to effectively close the language divide at the point of care. For example, in Switzerland, a study among asylum seekers showed that interpreter services led to more targeted health care, concentrating higher health care utilization into a smaller number of visits. Although the initial costs are higher, the results of this study indicate that the use of interpreter services is more cost-effective in the long-term.
From November 14-18, 2016, the GHDonline Population Health Community hosted a discussion about the impact of language barriers on access to health services, quality of care, and patient outcomes, and the role health systems can play to ensure safe and equitable care for patients who do not speak the local language. Themes, challenges, successes, and solutions shared are examined below.
Themes and challenges raised
Beyond verbal communication
- Communication goes well beyond words and language – it is essential for health care providers and interpreters to understand patients’ historical trauma as well as language needs, particularly amongst refugees.
- One participant cited a personal experience where interpreters from one country’s dominate ethnicity have triggered the trauma experienced by the country’s ethnic minorities, regardless of how professional and unbiased the interpreter has been. Providers and interpreters should consider patients’ ethnic and cultural factors in addition to the dominant language spoken in an individual's country of origin to understand the patient's language/interpretation needs.
- The gender and religion of the interpreter may also be of concern, particularly for patients whose cultural or religious backgrounds requires such interactions occur between individuals with similar backgrounds. Patients may also feel more comfortable with their medical needs being interpreted by someone of the same gender.
- Communication and translation are not just required for the patient-provider interaction, but for all written forms of communication in health care settings, including websites. A new provision in the Accountable Care Act requires enhanced signage to empower patients with knowledge that there are translation services available at no charge.
Effects on patient safety and outcomes
- When providers and medical staff are not able to adequately traverse language barriers, this contributes to the occurrence of medical errors. Professional interpreters are associated with an overall improvement of care for patients experience language barriers, including decreased communication errors and improved clinical outcomes.
- Without professional interpreters available, patients may be at the mercy of biased or medically unqualified individuals such as bi-lingual friends or family. This further increases the chances that the patient and provider will not receive accurate medical information, preventing patients experiencing language barriers from taking an active role in their own health care.
- Baseline health literacy may also be an issue, especially for populations that traditionally depend on community-based healers. The majority Americans do not get health information in a way they can use or easily understand. Medical terminology by itself is a challenge, and adding an additional language barrier magnifies the risk for error.
Time, cost, and capacity
- Using a qualified interpreter is best practice – Section 1557 of the Affordable Care Act requires qualified interpreters, leading to rising demand for professional language services. Unfortunately, medical information and decisions are often time sensitive, so it is common for providers to ask “whoever is available” to do the translating in a time crunch. These informal interpreters – such as family members or bilingual health care professionals – are usually not trained on the concept of communication during interpreting services, and can lead to communication errors.
- Without using objective, third party interpreters, there remains a risk of friends or family members asked to translate harboring hidden agendas, whether for cultural reasons, or to protect their loved one from a diagnosis. Additionally, using qualified professionals ensures the individual interpreting has medical knowledge and terminology that friends and family are unlikely to have experience with.
- Many patients and providers are used to utilizing an onsite or in-person interpreter, which may cause a time delay if one is not immediately available. It is easy to rely heavily on one modality for translation or interpretation services, yet many exist and all should be taken advantage of, even simultaneously. Proper introduction and education of alternative translation technologies, such as video or audio, are key to success.
- The use of video interpreting relies heavily on wireless networks, which may not be reliable in remote areas where video interpretation services are needed most.
Successes and solutions shared
Beyond verbal communication
- Interpreters should be well-versed not only in language interpretation and communication, but should also understand prior trauma and religious, ethnic, and cultural preferences. Since it very challenging to identify these factors during an initial visit, particularly when a language barriers exist, one solution could be to use a telephone interpreter to identify those cultural considerations. This option may also lessen feelings of intimidation or power imbalances that the patient might feel with an in-person interpreter. One participant also mentioned keeping language ID cards in the ward to more quickly assess the patient’s language and translation preferences.
- Document translation has and continues to have a critical role in providing quality care across language barriers.
- Posting basic information, such as signage or commonly used handout sheets, and making that information accessible to staff and patients is an effective way to communicate translation services are available. This simple solution should not be undermined by the desire for more sophisticated solutions. Similar solutions are being explored for website translation and web design for patient’s language needs.
Effects on patient safety and outcomes
- Professional interpreters should be used whenever possible, whether in-person, over the phone, or through video. Providers should asking untrained family and friends to translate medical jargon. Bilingual health care professionals may be helpful if they are formally trained in communication concepts during interpreting services.
Time, cost, and capacity
- Professional interpreters should be used whenever possible. Another option for medical facilities is to utilize Language Service Providers (LSPs). Through partnerships between LSPs and health care facilities, accountability and oversight lie with the LSP, not the health care system. Most major LSP's also have liability insurance built in to their business model, thereby further alleviating the burden of a hospital system.
- By partnering with LSPs, hospitals can also ensure they are utilizing the full package of interpretation technologies available to them, including: multiple modalities such as audio and video, industry and market updates, staff access to training and education, usage reports, and quality assurance processes.
- It is important not to rely on one type of modality, but to take advantage of the full suite of support that individual interpreters and technology can offer. Audio, video, written, and in-person translation options are all important components effective medical interpretation.
- Video Remote Interpreting (VRI) is a cost-effective way to provide timely interpretation services, especially in emergent situations. VRI with American Sign Language (ASL) communication capability is a great way for providers to serve the deaf community.
- Providers should ask patients to consider how they would want to receive health care information or news, and schedule interpreters accordingly. For example, scheduling over-the-phone interpreters for appointment reminders, video interpreters for short conversations, and in-person interpreters for longer or more sensitive discussion like new diagnoses.
- Involving an interpreter in provider interactions as quickly as possible is important to reducing medical errors and miscommunication. If an in-person interpreter is required but running late, call an audio or video interpreter to inform the patient of what is going on. It’s fine to start with one form of interpretation and transition to another – this reduces time wasted and can ease the patients fears and confusion while they wait.
- Written and oral translation services are also undergoing technological transformations, such as Translation Memory (TM), a database that captures, stores and re-uses repeated translated content for future use to expedite translation turnaround and reduce cost.
- Macrosimplification is the simplification of English text into ‘plain English’ to ensures that it actually connects with audiences of all backgrounds and education before being translated into another language. This process also reduces page count by 20-30%, increasing return on investment to end-users.
- Kale E, Kumar BN. Challenges in Healthcare in Multi-Ethnic Societies: Communication as a Barrier to Achieving Health Equity. In: Maddock J, ed. Public Health - Social and Behavioral Health. InTech; 2012. DOI: 10.5772/2242.
- Betancourt JR, Renfrew MR, Green AR. Improving Patient Safety Systems for Patients With Limited English Proficency: Agency for Healthcare Research and Quality; 2012. Available at: https://www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf.
Download: Bridging_the_Language_Gap.pdf (142.0 KB)