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[Interpretation in the Danish health-care system.]
Abstract
Communication between health professional and patient is central for treatment and patient safety in the health-care system. This systematic review examines the last ten years of specialist literature concerning interpretation in the Danish health-care system. Structural search in two databases, screening of references and recommended literature from two scientists led to identification of seven relevant articles. The review showed that professional interpreters were not used consistently when needed. Family members were also used as interpreters. These results were supported by international investigations.
... We found that interpretation in maternal health care was not always conducted with the use of professional interpreters or supplemented with extra time, which is in correspondence with the general picture of interpreter services within the Danish health care system [35]. However, this practice is against the national ANC policy [20], and inadequate interpretation has been shown to compromise communication and quality of care [36,37]. ...
Inequity in immigrants’ health during pregnancy and childbirth has been shown. We studied the Danish regional organization of public midwifery-based antenatal care (ANC) for immigrant women to assess the strengths and weaknesses of organizing ANC as either universal or immigrant-targeted. A telephone survey in 2012 to all the Danish maternity wards (n = 20) was conducted. Semi-structured interviews with midwives providing targeted care (n = 6) were undertaken and characteristics of care were qualitatively analyzed, having the immigrant density of the facilities, the Danish ANC policy, and theories of cultural competence as the frame of reference. Six maternity wards were providing immigrant-targeted ANC. Targeted care implied longer consultations and increased attention to the individual needs of immigrant women. At these facilities, navigation in the health care system, body awareness, and use of interpreter services were key topics. The selection of women for targeted care was based on criteria (including names) that risk stigmatizing immigrant women. The arguments for not providing targeted care included that immigrant-targeted care was considered stigmatizing. Current universal care may overlook the needs of immigrant women and contribute to inequities. A strategy could be to improve dynamic cultural competencies of midwives, interpreter services, and flexibility of the care provision of the universal ANC system.
Aim
We aimed to explore how interpreters experienced being part of a special designed health introduction course and to obtain their perspectives on the learning process. The overall aim was to improve health care to patients with language barriers.
Design
With a hermeneutic phenomenological approach, we used participant observations as a method for collecting data.
Method
The teaching methods used were case‐based learning, role‐play and active involvement including dialogs, discussions and critical reflections. The interpreters were divided into teams of 10–15 interpreters. Over the duration of 6 weeks, teaching sessions were conducted, with 3 hr/week planned.
Results
The findings emphasize the importance of providing the interpreters with education, supervision and a work environment where they can confidentially share and get competent feedback on their experiences and linguistic skills, in order to ensure patients get the correct information in their native language.
About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation.
To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation.
During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence.
Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media.
Errors in medical interpretation are common, averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.
We investigated inequalities in self-rated health between immigrants, their descendants, and ethnic Danes and explored mediation by socioeconomic position and interactions between country of origin and socioeconomic position.
Cross-sectional survey data on self-rated health from 4,985 individuals aged 18-66 years including immigrants from seven non-Western countries, their descendants, and ethnic Danes was linked to registry-based data on education, employment status, and income as indicators of socioeconomic position. Using multiple logistic regression analysis, we estimated the association between country of origin and self-rated health.
Immigrants reported poorer health compared with ethnic Danes [age-adjusted odds ratio (OR) = 2.0-7.3 for men; 2.1-10.5 for women, dependent on country of origin] as well as their descendants (OR = 1.6-3.8 for men; 1.5-2.0 for women). Adjustment for socioeconomic position attenuated this association. Stratified analysis indicated that the effect of socioeconomic position on self-rated health varied across the groups.
Policies addressing inequalities in health between immigrants, their descendants, and ethnic Danes should target underlying socioeconomic inequalities. Further research of the effects of socioeconomic position on health among immigrants and descendants is needed.
Language barriers have a major impact on both the quality and the costs of health care. While there is a growing body of evidence demonstrating the detrimental effects of language barriers on the quality of health care provision, less is known about their impact on costs. This purpose of this study was to investigate the association between language barriers and the costs of health care.
The data source was a representative set of asylum seekers whose health care was provided by a Swiss Health Maintenance Organisation (HMO). A cross-sectional survey was conducted: data was collected on all the asylum seekers' health care costs including consultations, diagnostic examinations, medical interventions, stays in the clinic, medication, and interpreter services. The data were analysed using path analysis.
Asylum seekers showed higher health care costs if there were language barriers between them and the health professionals. Most of these increased costs were attributable to those patients who received interpreter services: they used more health care services and more material. However, these patients also had a lower number of visits to the HMO than patients who faced language barriers but did not receive interpreter services.
Language barriers impact health care costs. In line with the limited literature, the results of this study seem to show that interpreter services lead to more targeted health care, concentrating higher health care utilisation into a smaller number of visits. Although the initial costs are higher, it can be posited that the use of interpreter services prevents the escalation of long-term costs. A future study specially designed to examine this presumption is needed.
Due to international migration, health care professionals in Switzerland increasingly encounter language barriers in communication with their patients. In order to examine health professionals' attitudes and practices related to healthcare interpreting, we sent a self-administered questionnaire to heads of medical and nursing departments in public healthcare services in the canton of Basel-Stadt (N = 205, response rate 56%). Strategies used to communicate with foreign-language speaking patients differed, depending on the patient's language. While nearly half of respondents relied on patients' relatives to translate for Albanian, Tamil, Bosnian, Croatian, Serbian, Portuguese and Turkish, a third did so for Spanish, and a fourth did so for Arabic. Eleven percent relied on professional interpreters for Spanish and 31% did so for Tamil and Arabic. Variations in strategies used appear to mainly reflect the availability of bilingual staff members for the different languages. Future efforts should focus on sensitizing health professionals to the problems associated with use of ad hoc interpreters, as well as facilitating access to professional interpreters.
Language barriers complicate physician-patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood.
To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP).
Qualitative study using in-depth interviews.
Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services.
An interview guide was used to explore decision making about interpreter use.
Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as "getting by;" 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician's use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.
Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to "get by" without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.
We assessed the impact of interpreter services on the cost and the utilization of health care services among patients with limited English proficiency.
We measured the change in delivery and cost of care provided to patients enrolled in a health maintenance organization before and after interpreter services were implemented.
Compared with English-speaking patients, patients who used the interpreter services received significantly more recommended preventive services, made more office visits, and had more prescriptions written and filled. The estimated cost of providing interpreter services was $279 per person per year.
Providing interpreter services is a financially viable method for enhancing delivery of health care to patients with limited English proficiency.
To examine the effect of Spanish interpretation method on satisfaction with care.
Self-administered post-visit questionnaire.
Urban, university-affiliated walk-in clinic.
Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems.
Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. "Language-concordant" patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P < .01 and P = .007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P > .2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02).
Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.
To determine the impact of interpreters and bilingual physicians on emergency department (ED) resource utilization.
Cohorts defined by language concordance and interpreter use were prospectively studied preceding and following the availability of dedicated, professional medical interpreters.
Pediatric ED in Chicago, Ill.
We examined 4146 visits of children (aged 2 months to 10 years) with a presenting temperature of 38.5 degrees C or higher or a complaint of vomiting or diarrhea; 550 families did not speak English. In 170 cases, the treating physician was bilingual. In 239, a professional interpreter was used. In the remaining 141, a professional medical interpreter was unavailable.
Incidence and costs of diagnostic testing, admission rate, use of intravenous hydration, and length of ED visit.
Regression models incorporated clinical and demographic factors. Compared with the English-speaking cohort, non-English-speaking cases with bilingual physicians had similar rates of resource utilization. Cases with an interpreter showed no difference in test costs, were least likely to be tested (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.56-0.97), more likely to be admitted (OR, 1.7; 95% CI, 1.1-2.8), and no more likely to receive intravenous fluids, but had longer lengths of visit (+16 minutes; 95% CI, 6.2-26 minutes). The barrier cohort without a professional interpreter had a higher incidence (OR, 1.5; 95% CI, 1.04-2.2) and cost (+0.24-$11.21) for testing and was most likely to be admitted (OR, 2.6; 95% CI, 1.4-4.5) and to receive intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3), but showed no difference in length of visit.
Decision making was most cautious and expensive when non-English-speaking cases were treated in the absence of a bilingual physician or professional interpreter.
The study was conducted to investigate the impact of an Interpreter Service on intensity of Emergency Department (ED) services, utilization, and charges. This study describes the effects of language barriers on health care service delivery for the index ED visit and a subsequent 90-day period. In all 26,573 ED records from July to November, 1999, resulted in a data set of 500 patients with similar demographic characteristics, chief complaint, acuity, and admission rate. Noninterpreted patients (NIPs) who did not speak English had the shortest ED stay (LOS) and the fewest tests, IVs and medications; English-speaking patients had the most ED services, LOS, and charges. Subsequent clinic utilization was lowest for NIPs. Among discharged patients, return ED visit and ED visit charges were lowest for interpreted patients (IPs). Use of trained interpreters was associated with increased intensity of ED services, reduced ED return rate, increased clinic utilization, and lower 30-day charges, without any simultaneous increase in LOS or cost of visit.
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