Article

Providers’ Perceptions of Medical Interpreter Services and Limited English Proficiency (LEP) Patients: Understanding the “Bigger Picture”

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Abstract

Patient’s ability to understand and effectively communicate health information facilitates disease prevention, self-management of illness, the adoption of healthy behaviors, and their ability to act on important public health information. However, patients who have limited English proficiency (LEP) are significantly disadvantaged. Previous studies have shown the benefit of medical interpreter services in bridging the health communication gap between patients and providers. This qualitative study, focusing on medical interpreter utilization within obstetrical and neonatal services, provides perspectives from multiple types of providers to further explore the role of medical interpreter services and specific barriers to the use of such services. Five separate focus groups were conducted with postpartum nurses, labor and delivery/triage nurses, obstetrics and gynecology (OBGYN) resident physicians, neonatal intensive-care unit (NICU) nurses, and faculty physicians, nurse practitioners, and midwives. The data show that barriers to the utilization of professional medical interpreters can be categorized by distinct but related institutional- and individual-level factors. Further interpretation of the barriers, however, suggests that providers’ use/non-use of interpreter services is merely one piece of a much “bigger picture” regarding difficulties and challenges in delivering care to a growing culturally diverse patient population, and that these cultural challenges, not just the availability of interpreter services, may affect providers’ ability to deliver effective and efficient care. It is argued that simply adding additional communication-based resources may not be sufficient to impact providers’ attitudes and behaviors or the overarching organizational culture regarding LEP patients.

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... A qualitative study revealed that suboptimal interpreter scheduling and a limited number of available in-person interpreters are barriers to the provision of language services when they would be preferred. [14] Many providers also "expressed dissatisfaction, distrust, and frustration with the telephonic interpretation", further limiting receipt of needed services. [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. ...
... [14] Many providers also "expressed dissatisfaction, distrust, and frustration with the telephonic interpretation", further limiting receipt of needed services. [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. [14] These methods are utilized even when providers are aware of the benefit of language services and the associated legal and medical risk. ...
... [14] When language services are unavailable or when there is a time constraint, providers utilize ad hoc methods to communicate with patients, such as consulting the internet or smartphone translation applications, getting by with gestures, relying on untrained bilingual staff or family members, or relying on the provider's limited foreign language ability. [14] These methods are utilized even when providers are aware of the benefit of language services and the associated legal and medical risk. [14] 1.4.2 ...
Article
Objective: The objective of this paper is to highlight a study on optimizing the full-time equivalent (FTE) for Spanish and Mandarin interpreters at Christiana Care Health System. In this study, there were multiple challenges that needed to be addressed, and a multi-method approach was taken.Methods: These methods include: (1) time-motion study to quantify interpreter workflow and variability of duration of time needed for each task; (2) an integer program to optimize the number of interpreters needed per hour based on historical demand patterns for interpreter services; (3) Discrete-Event Simulation (DES) to examine the use of agency interpreters in order to meet demand; (4) cost modelling to convert FTEs and the use of agency interpreters into overall costs to the hospital; and (5) sensitivity analysis to evaluate alternative number of interpreter FTEs and their corresponding costs to the hospital.Results: Overall cost to the hospital is predicted to decrease with additional FTE interpreters, up to a threshold level above which the cost will start to increase. Through this innovative methodology used in this paper, we predict that hiring 3.5 more FTEs for Spanish interpreters will result in 9.07% of cost savings, and predict that hiring one FTE for Mandarin interpreters will result in 25.87% in cost savings compared to the current expense of providing Mandarin language interpretation.Conclusions: Contrary to intuition, increasing number of FTEs results in cost savings. Besides the financial benefit, hospitals will also be able to ensure the quality of health services that Limited English Proficiency (LEP) patients and families receive.
... Cultural literacy enhances evidence-based findings that positive patient-provider relationship improves patient health outcomes [7,8,12,[29][30][31]. Although the patient-provider relationship is an intrinsically valued goal in healthcare, when providers encounter an LEP patient, the challenges of language barriers may overshadow this goal [32]. This challenge can hinder building trust. ...
... Awareness of cross-cultural differences in cultural orientation can improve how providers communicate with their LEP patients. Patient-centered communication means engaging with their patient, which can lead to a positive perception of care [26,32]. To be truly patient-centered, the provider cannot remain culturally neutral but rather needs to be more culturally sensitive, which can be done by increasing one's cultural literacy [11]. ...
Article
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We explored how addressing culture may improve patient-provider relationships and reduce health disparities for racial and ethnic individuals with limited English proficiency (LEP). We analyzed qualitative data collected to explore health disparities in preventive cancer screenings for Hmong and Spanish-speaking LEP patients in a large Midwest healthcare system. We interviewed 20 participants (10 from each group) and the audiotaped interviews were transcribed verbatim, then back translated focusing on meaning. Data was analyzed using content analysis. Two themes are: conversation is relational and quality time is valued. Good communication skills involve the amount of conversation, clear explanations, and engaging with the patient. Quality of time meant physical time spent with patient and the task-oriented nature of the encounter. Cultural literacy in healthcare practice helps to understand the whole patient rather than focusing on the symptoms of illness. Patients should not be treated in isolation of their culture. A patient-centered approach to care means physicians should not remain culturally neutral but be more culturally sensitive. We propose steps to reduce disparities by increasing the awareness of cultural literacy for physicians to improve patient-provider relationship.
... The researcher focuses on in-person interpretation in this study, which occurs face-toface between the interpreter and the patient. As Michalec, et al., (2015) reported, several patients indicated that having an in-person interpreter would put them at ease, allow for the reception/interpretation of emotions expressed through body language, and increase the intimacy of the conversation. However, a medical interpreter's level of ability and expertise is often a constraint on providing an outstanding interpretation session. ...
... According to hospital policy at the field site, patients have the right to request interpreter services at any time during their hospital visit, and also have the right to decline the offered services of a certified staff interpreter in favor of their own representative, such as a bilingual family member. However, as Michalec, Bell, Ehrenthal, Maiden, and Ortiz (2015) explains, even though there have been federally established laws and policies that dictate the use of language services for patients of limited English proficiency, such as Title VI, providers across the board have expressed that there are multiple institutional and practical factors that influence their decision to use or not use an interpreter. ...
Thesis
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This thesis explores the agency (decision making ability) and resource-seeking behaviors of Spanish-speaking patients of limited English proficiency (LEP) when communicating with a biomedical physician through an interpreter. It aims to understand how power dynamics in these mediated encounters may influence patient agency or the exchange of information regarding healthcare resources (e.g., inpatient, outpatient, or community resources). It clarifies how interpreters are brokering access to resources within the U.S. biomedical healthcare system, as well as how patients and providers gauge the effectiveness of interpreter mediation for obtaining knowledge of/access to appropriate resources. My research seeks answers on how the presence of a cultural and linguistic intermediary (an interpreter, potentially of different ethnicity or race as the patient) during interactions between patient and provider changes power dynamics during communication between parties. This thesis explores these queries from the theoretical framework of practice theory. Methods of data collection include participant observation and semi-structured interviews, and I use Foucauldian discourse analysis to scrutinize findings.
Article
Background: Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC. Methods: A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status. Results: Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation. Conclusions: In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.
Article
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Article
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Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
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Partially bilingual physicians may weigh a number of factors in deciding whether to use their own limited non-English language skills or call an interpreter when caring for patients with limited English proficiency. Yet little is known about this decision process or how it might fail. In a patient safety approach to exploration of this complex, potentially high-stakes decision, key risk factors that may contribute to miscommunication during health care encounters in non-English languages were identified. The Healthcare Failure Mode and Effects Analysis (HFMEA) method was adapted to examine the decision process. An initial set of possible decision factors was presented to a national expert panel of eight physicians, who modified and expanded the list of factors and then rated each according to four scales: Frequency, Importance, Amenability to Intervention, and Detectability. A "5 Whys" approach was used to examine underlying causes of these failure modes and generate potential interventions. Nine factors were described that could lead physicians to use their own skills rather than an interpreter when that decision might pose unacceptable risk. The highest-priority factor was lack of knowledge regarding the value of using a trained interpreter and how to work with a trained interpreter effectively. For the top failure mode, a sample hypothetical 5 Whys exercise shows how to examine potential underlying causes and produce recommendations. A variety of discrete factors can have important effects on physicians' decisions to use their own non-English language skills or an interpreter. Because this decision can affect patient safety, organizations and policy makers should use these factors to guide local efforts to examine these issues and develop quality improvement and safety activities.
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Preterm birth rates are higher in the United States than in most industrialized countries, and have been rising steadily. Some attribute these trends to changing demographics, with more older mothers, more infertility, and more multiple births. Others suggest that changes in obstetrics are behind the trends. We sought to determine what the preterm birth rate in 2004 would have been if demographic factors had not changed since 1989. We examined complete US birth certificate files from 1989 and 2004 and used logistic regression models to estimate what the 2004 preterm birth rates (overall, spontaneous, and medically induced) would have been if maternal age, race, nativity, gravidity, marital status, and education among childbearing women had not changed since 1989. While the overall preterm births increased from 11.2% to 12.8% from 1989 to 2004, medically induced rates increased 94%, from 3.4% to 6.6%, and spontaneous rates declined by 21%, from 7.8% to 6.2%. Had demographic factors in 2004 been what they were in 1989, the 2004 rates would have been almost identical. Changes in multiple births accounted for only 16% of the increase in medically induced rates. Our analysis suggests that the increase in preterm births is more likely due primarily to changes in obstetric practice, rather than to changes in the demographics of childbearing. Further research should examine the degree to which these changes in obstetric practice affect infant morbidity and mortality.
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Language barriers present a major obstacle to minority ethnic communities accessing primary healthcare. Whereas it is recognised that interpreting services are generally inadequate and inappropriate reliance is placed on family members to interpret, little is known about how nurses working in primary care utilise interpreters to overcome language barriers. The present paper reports on a study examining the utilisation of interpreting services by a range of primary care nurses from the perspectives of the nurses, interpreters and minority ethnic communities. Focus groups were undertaken with five separate groups of district nurses, health visitors, practice nurses, community midwives and specialist nurses, three groups of interpreters from different interpreting services, and five groups of participants from the main community languages in the locality where the study was undertaken (i.e. Arabic, Bengali, Cantonese, Somali and Urdu). Focus group discussions were tape-recorded and subsequently transcribed. Data analysis drew upon the principles of 'framework' analysis. The use of interpreters by primary care nurses varied considerably. Nurses who had received training in using interpreters and who had most control over the timing of patient visits were more likely to use interpreting services. Inadequate training of both nurses and interpreters adversely affected the quality of interaction where interpreters were used. Primary care nurses acted as gatekeepers to interpreting services. Whereas interpreting services were generally perceived to be inadequate, many nurses were accepting of the status quo and prepared to rely on family members to interpret rather than champion the need to improve services.
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To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients. A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library. Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care. In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.
Article
This paper explores physician perceptions of the ways professional and family interpreters affect their performance of doctor-communication tasks described in the Calgary-Cambridge Framework. Physicians' (19) encounters with patients (24) accompanied by an interpreter were videotaped. Stimulated recall was used to elicit each of the participants' perceptions of the clinical encounter. We analyzed transcriptions of the physician interviews using Atlas-ti software. Physicians perceived all communication tasks to be more difficult using an interpreter than when one was not needed. Physicians perceived family interpreters to be less skilled translators than professional interpreters. Physicians expected professional interpreters to serve as culture brokers at least some of the time. Although only some family interpreters were also caregivers, physicians assumed that all of them fulfilled caregiver roles. With professional interpreters, physicians follow communication rules they were taught. In contrast, physicians act as though these rules are not relevant with family interpreters who they treat as caregivers. Guidelines to working with an interpreter should include directives on working with both professional and family interpreters, describing the similarities and differences with each type, and modifying the clinical encounter process to correspond to those attributes.