Boston University
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Theses & Dissertations Boston University Theses & Dissertations
2018
Educational survey to increase
professional interpreter use
https://hdl.handle.net/2144/33017
BOSTON UNIVERSITY SCHOOL OF MEDICINE
Thesis
EDUCATIONAL SURVEY TO INCREASE PROFESSIONAL INTERPRETER USE
by
CAROLINE YANG
B.S., Boston University, 2014
Submitted in partial fulfillment of the requirements for the degree of
Master of Science 2018
© 2018 by
Approved by
First Reader
Mary Warner, M.M.Sc., PA-C Assistant Professor of Medicine
Second Reader
John R Weinstein, Ph.D.
ACKNOWLEDGMENTS
I would to thank the entire Boston University PA program for taking a chance on me and believing that I have what it takes to be a PA. Thank you Mary Warner for all of your help and support on this thesis, but more importantly throughout PA school. Thank you Dr. Weinstein for your guidance through this thesis process. Thank you family and friends for all of your support.
EDUCATIONAL SURVEY TO INCREASE PROFESSIONAL INTERPRETER USE
CAROLINE YANG ABSTRACT Background
The population of limited English proficiency (LEP) patients has grown significantly and healthcare professionals must overcome language barriers to provide high quality healthcare to these patients. Language barriers create healthcare disparities and affect quality of care, health outcomes, patient safety, and access to health services in LEP patients.
Several methods are used to foster language-concordant encounters, most importantly professional interpreter services. Although the use of professional
interpreters is superior to other methods, utilization of professional interpreters remains low. Common reasons for insufficient interpreter use by healthcare professionals include inconvenience related to obtaining an interpreter and the decreased time available for patient interaction. However, interventions that attempt to mitigate these limitations have increased usage of professional interpreters but not to a sufficient degree. Low
professional interpreter use is a multifactorial problem and several factors are still unknown. Little existing research has focused on LEP patients’ knowledge and
perceptions of language barriers and professional interpreter use and, thus, not much is known about patient barriers to professional interpreter use. That which is known includes that the majority of LEP patients are unaware of their right to request a
professional interpreter at no cost. Some have feelings of fear and embarrassment that prevent them from requesting an interpreter. Patients want a professional interpreter based on subjective measures rather than empirical research. It has yet to be determined whether or not patients are aware of the existing research surrounding the negative effects of language barriers and benefits of professional interpreter use. It is difficult to know if there is a lack of knowledge and if additional knowledge would prompt more patients to request professional interpreters.
Methods
The study is a non-randomized trial with a control and intervention group. The
intervention will be a pre-appointment survey about language barriers and interpreter use that acts as both an educational tool and a method to assess patients’ knowledge about language barriers and professional interpreter use. Each study group will have a 3-week recruitment period. After their appointments, both groups will receive a post-appointment survey to determine if an interpreter was used. Analysis of the proportions of patients who used an interpreter in the control and intervention group will be compared using Chi-square statistical testing to determine if the survey instrument increased interpreter use.
Conclusion
This study will demonstrate if LEP patients lack knowledge regarding language barriers and professional interpreter use. It will also provide evidence of a potential association between this lack of knowledge and low professional interpreter use.
TABLE OF CONTENTS
TITLE………...i
COPYRIGHT PAGE………...ii
READER APPROVAL PAGE………..iii
ACKNOWLEDGMENTS ... iv
ABSTRACT ... v
TABLE OF CONTENTS ... vii
LIST OF ABBREVIATIONS ... ix
INTRODUCTION ... 1
Background ... 1
Statement of the Problem ... 2
Hypothesis... 3
Objectives and specific aims ... 3
REVIEW OF THE LITERATURE ... 5
History... 5
The Effect of Language Barriers on Patient Care ... 6
Types of Translation Services ... 9
Use of Interpreters by Healthcare Professionals ... 12
METHODS ... 22
Study design ... 22
Recruitment, study population and sampling ... 22
Treatment (or intervention) ... 23
Study variables and measures ... 24
Data collection ... 24
Data analysis ... 25
Timeline and resources ... 25
Institutional Review Board ... 26
CONCLUSION ... 27
Discussion ... 27
Summary ... 30
Clinical and/or public health significance ... 31
APPENDIX 1 ... 33
APPENDIX 2 ... 35
LIST OF JOURNAL ABBREVIATIONS ... 36
REFERENCES ... 38
LIST OF ABBREVIATIONS
INTRODUCTION Background
According to the 2010 US Census, 13% of the US population is foreign-born, with several states having upwards of 30%.1 It is estimated that about 85% of the foreign-born population spoke a language other than English before immigrating.1 The limited English proficiency (LEP) speaking-population has grown significantly and is dispersing to areas throughout the United States with previously small immigrant populations.1 It is, therefore, of increasing importance to address issues that can arise when caring for this population. More healthcare professionals inexperienced with encountering LEP patients are now facing the challenges of language barriers. Although language is not the only element that leads to suboptimal care of LEP patients, it has proven to be one of the most significant factors in creating healthcare disparities.2
Over the past decade, an increasing amount of research has been dedicated to language barriers.3 Studies have shown that comprehension, adherence, quality of care, and patient satisfaction are all affected by language barriers, which negatively impact the overall healthcare outcomes of LEP patients.4 Negative healthcare outcomes include a
higher risk of adverse events, increased readmission rates, increased 30-day mortality, and decreased access to preventative care.4,5,6
Medical interpreters are used to create language-congruent communication between healthcare professionals and LEP patients to overcome language barriers. Several studies have compared different modes of interpretation and found that professional interpretation use was associated with better quality of care and is
considered the gold standard for overcoming language barriers.7 Use of professional
interpreters among LEP patients is associated with improved clinical outcomes, increased patient comprehension, greater patient satisfaction, and equal access to health care and preventative services.7 Additionally, interpretation errors leading to negative clinical consequences are more common with ad-hoc interpreter use.8 When a professional interpreter is not used, healthcare professionals often do not check patients’
comprehension, patients may not voice difficulty understanding, and patients may not be aware of when they lack comprehension.9,10,11
Statement of the Problem
Although there is substantial evidence to support the use of a professional interpreters as the gold standard in communicating with LEP patients, professional interpreter use is inconsistent and not widely adopted.5,12 Common reasons for healthcare professionals’ poor use of professional interpreters include increased demand on their time and limited availability of interpreters.13,14 However, even in healthcare settings where access to professional interpreter services are quickly accessible and available 24/7, professional interpreters are still underused.15 Previous QI studies to improve professional interpreter use have only targeted healthcare organizations and clinicians. They are expensive and have made only small impacts on professional interpreter use.3,16–
18 These results indicate that there may be other unaddressed reasons for poor use, such as
It is unclear if LEP patients are knowledgeable about the impact of language barriers and the benefits of professional interpreter use. The majority of LEP patients are not even aware that they are entitled to a professional interpreter at no cost.19 Patients also base their need for an interpreter based on subjective measures, rather than empiric research.20 This suggests that patients are not well-informed and are lacking the
knowledge needed to make an informed decision regarding interpreter use, a decision that can affect their healthcare outcomes.
Hypothesis
We hypothesize that an educational survey completed by LEP patients prior to their scheduled appointments will be associated with an increase in professional interpreter use.
Objectives and specific aims
The objective of this study is to increase professional interpreter use in an outpatient healthcare setting. This study will assess patients’ knowledge about the impact of language barriers and the importance of professional interpreter use. It will also demonstrate if patient education is a potential method to increase interpreter use. Specifically, this study aims to:
• Determine LEP patient knowledge about the impact of language barriers and the benefits of professional interpreter use through a brief pre-appointment survey.
• Assess whether use of the educational survey is associated with an increased rate of professional interpreter use.
• Identify a possible association between patients’ professional interpreter use and lack of knowledge about language barriers and need for professional interpreter use.
REVIEW OF THE LITERATURE History
Limited English proficiency (LEP) is defined as the limited ability to speak, write, read, or understand English.21 The number of people with LEP increased from 14 million to 25.1 million between 1990-2013, a nearly 80% increase.22 Historically, immigrants have settled in immigration-destination states, such as New York and California, but are now settling in substantial numbers in previously nontraditional immigrant-destinations all over the United States.23 Between the 1990 and 2000 censuses, the states of Georgia, Arkansas, Oregon, Utah, Nevada, and North Carolina saw increases in their LEP
populations of greater than 100%.24 The increasing rates of immigration and dispersion of immigrants settling in areas of relatively homogeneous English-proficient populations has led to an increasing number of localities needing to confront the issue associated with language barriers.24 Many healthcare professionals inexperienced with addressing
language barriers in their practice are now facing the challenge of communicating with LEP patients.25
Title VI of the Civil Rights Act of 1964 was a United States law requiring federally funded healthcare organizations to provide meaningful access to language services for LEP patients.26 However, the law was not well-enforced and healthcare professionals were not fulfilling the federal right to language services.19 In 2000, President Clinton issued an Executive Order to raise awareness of the federal law with specific guidance on how healthcare organizations could meet the law requirement.27
in response, the Bush Administration made revisions and reissued the Policy Guidance in 2003.28 The reissuance brought more publicity to the growing issue of language barriers in healthcare and the potential negative effects on patient care. 29
Since 2003, there has been a substantial increase in research on language barriers and healthcare with the majority of the recent research focusing on health outcomes, patient satisfaction, barriers to access of preventative services, and interpreting practices.3
In the United States, Spanish has been and continues to be the most often studied
language with about 65% of the LEP population speaking it.23 With the growing body of research focusing on language barriers, healthcare professionals now have a better understanding of the issues arising from communication with LEP patients. Despite this, there is an insufficient number of studies performed demonstrating the effectiveness of interventions to overcome language barriers. This is potentially due to limited funding opportunities for intervention studies, which tend to be more costly.3
The Effect of Language Barriers on Patient Care
The determinants of healthcare quality are multifactorial. Although several studies have shown that factors, such as race and ethnicity, influence healthcare outcomes,
language barriers prove to be one of the greatest causes of healthcare disparities.2 It has been well established that language barriers threaten patient safety, quality of hospital care, patients’ health, and access to health.4,6
Existing research indicates that language barriers may negatively impact utilization of preventative services.30 Patients with LEP are less likely to seek medical
care over their lifetime and less likely to receive necessary medical services when they do seek out care.5,31 Even after controlling for factors such as literacy, insurance status, socioeconomic status, and ethnicity, LEP patients have fewer physician visits and receive fewer preventative services. They also have lower rates of adherence to treatment plans and follow-up for chronic illnesses.7 This is associated with greater morbidity and mortality from diseases, increased cost of healthcare, and overall poorer health status.32
When languages barriers are not addressed appropriately, they can negatively impact quality of care received and may have negative consequences on treatment decisions.33 It is of great importance for healthcare professionals to discuss details of a diagnosis or treatment with patients.34 A vital component of quality patient-centered care includes patient involvement in treatment decision-making and the ability for patients to share their concerns and preferences with clinicians.35 However, patients must be able to understand what is communicated to have an equal part in treatment decision-making.36 Misunderstandings arising from unaddressed language barriers may lead to patients failing to comply with medical instructions or electing against having potentially life-saving treatment.33 Therefore, language concordance between patients and healthcare
professionals is essential for LEP patients to make informed treatment decisions.
Language barriers pose a serious safety concern for LEP patients. Communication problems are the primary cause of about 60% of all hospital documented serious adverse events with research suggesting that LEP patients are more likely to experience these adverse events.37,38 Additionally, adverse events were more likely to result in serious
experienced adverse events with physiological or mechanical harm compared to less than 30% of English-proficient patients.39 Of the adverse events experienced by LEP patients, about 46% of those ranged from moderate temporary harm to death, compared to 24% of English-proficient patients.39 Wasserman et al. found that a majority of the adverse events were related to misuse of interpreter services, which included situations with no
interpreter present, use of family to interpret, and clinicians using limited language skills to converse.38 It is clear that interpretation services are essential to increase LEP patients’ safety.
Language barriers have been shown to be a major predictor of hospital admission outcomes for LEP patients. One study examined whether patients’ primary language has an influence on hospital outcomes using measurements of hospital costs, length of stay, and odds for 30-day readmission or 30-day mortality.6 Through multivariate models that examined the effects of language of those that participated in the study, the authors showed higher odds of readmission at 30-days post-discharge for LEP patients.6 Other studies have demonstrated that patients who do not speak English experience longer lengths of stay and may encounter more adverse events during their hospital stay.39 These
studies highlight the significant disparities that occur with admissions of LEP patients, times where their patient’s health is particularly vulnerable.
LEP patients are not only negatively affected by outcomes secondary to language barriers during hospital admission; language barriers negatively impact hospital discharge outcomes as well. A study investigated the association of language barriers with patient comprehension of discharge instructions.40 The LEP patients demonstrated low rates of
understanding for necessary follow-up appointments after discharge and the purpose of new medications upon discharge.40 Compared to English-proficient patients, LEP patients were less likely to know either the category of their medication alone or both the category and purpose of their medication.40 The study also demonstrated that use of professional interpreters to communicate discharge instructions and information to LEP patients resulted in similar understanding to that of English-proficient patients.40
Patient satisfaction is becoming an increasingly important piece of healthcare quality that is also negatively affected by language barriers. Low patient satisfaction is associated with decreased treatment plan compliance, increased complaints, and
decreased willingness to return for follow-up care.41 Language-discordant interactions are associated with low levels of patient satisfaction, whereas interactions using interpreters are associated with improved levels of satisfaction.42 Thus, poor patient satisfaction may negatively impact the overall healthcare quality of LEP patients. This should stress the importance of language-concordance during healthcare encounters.
There are expanding efforts to increase language-concordant interactions through the use of medical translation services to optimize healthcare quality in the LEP
population. Doing so may improve patient healthcare outcomes, increase patient satisfaction, and decrease unnecessary costs of caring for LEP patients.
Types of Translation Services
Research investigating the impact of language barriers on healthcare suggests that interpretation services can help deliver better quality care to patients. Medical
interpretation strategies and use have been increasing as the LEP population has grown through the decades and have been described along three different dimensions.43 The first dimension is the level of training of the interpreter, whether they are professional or ad-hoc. Professional interpreters are those who have received formal medical interpretation training, whereas ad-hoc interpreters typically refer to untrained staff, family, or
friends.43 The second dimension describes the location of the interpreter, whether they
interpret during a medical visit in person or remotely via video or telephone
conferencing.43 The final dimension is the manner in which the interpretation occurs, relaying the message as quickly as possible after verbalization from the patient or
clinician or translating after the patient or clinician finishes a block of speech.43 Different methods are used in clinical practice and each have unique strengths and weaknesses.44
Professional medical interpreters are trained and certified to meet national standards to ensure patient safety and to prevent interpretation error, omission of information, and accurately translate medical terminology. A comparison study was performed to quantify interpreter errors between professional and ad-hoc interpreters through analysis of audiotapes of Emergency Department encounters.8 The most common
error found in the study were omissions, defined as a word or phrase uttered by a clinician that was not interpreted by the interpreter, which accounted for 47% of all errors.8 The second most common error was false-fluency errors, defined as an interpreter using a word or phrase that does not exist in that particular language or an incorrect word or phrase that substantially alters the meaning, which accounted for 26% of errors.8
errors.8 More importantly, ad-hoc interpreters were associated with approximately double
the odds of interpretation errors with potential clinical consequences.8 Patient safety is at great risk when ad hoc interpreters are used and efforts to increase professional
interpreter use are necessary.
Since the Executive Order to provide language services was issued, several hospitals and outpatient offices have responded to the increase in LEP patients by establishing language access services, such as professional in-person interpreters,
telephone interpreters and trained bilingual staff, but have also relied on ad hoc bilingual staff, friends, and family.5,27 Professional interpreters are considered the best tool to overcome language barriers in healthcare with overall improvements of healthcare for LEP patients.7 The use of professional interpreters was associated with greater quality
care compared to ad-hoc interpreters with increases in patient comprehension, improved clinical outcomes, greater patient satisfaction with communication, equalized health care access and clinical services for LEP patients.7 The growing volume of research
associating higher quality care with professional interpreter use has caused a shift in the medical community to strive for increased use of professional interpreters.
Despite the evidence of benefits and improvement in quality of care among LEP patients with professional interpreter use, several studies demonstrate the underutilization of professional interpreters by healthcare professionals.5,12 Use of interpreter services is often sporadic and dependent on a clinician’s own initiation.45 On study conducted in a hospital with access to professional interpreters 24 hours per day found that clinicians often relied on their own limited language skills, patients’ family members, or untrained
interpreters to communicate with LEP patients.15 Professional interpretation services
were used only 42% of the time despite availability of professional interpretation services at any time.15 In order to increase professional interpreter use, studies aimed to uncover the reasons for healthcare professionals’ low use.
Use of Interpreters by Healthcare Professionals
While an increasing number of healthcare organizations are providing rapid access to professional interpreters, the resources continue to be infrequently utilized during interactions with LEP patients. A qualitative study using in-depth interviews investigated the reasons for professional interpreter underuse.13 Although the clinicians in the study knew how to access interpreter services and were aware that using professional interpreters contributes to higher quality care, they opted to use other methods of
interpretation.13 Reasons for limited professional interpreter use include increased demands on their time, such as having to wait to connect with a telephone interpreter or in-person interpreter and the additional time required to speak with a patient through an interpreter.13 The clinicians reported they were able to communicate using limited second
language skills, gestures, or family members and often only used professional interpreters for more complex interactions.13 When professional interpretation was not used,
clinicians noted poor history taking, the inability to obtain potentially important details from patients, and sub-optimal physical exam results.13 The clinicians admitted to feelings of dissatisfaction with the care provided to the LEP patients.13 Another finding
common practice with unclear standards for communication with LEP patients.13 Overall,
the findings of this study suggest that increased availability of interpreter services and education of the clinicians on how to access the services would be unlikely to
significantly increase interpreter use.13 These results may not be generalizable to other smaller clinical settings with fewer resources, but it calls into question the practices of interpreter use in other healthcare organizations with more limited access to language services.
Another study assessing clinicians’ perception of professional interpreter services found similar reasons for poor professional interpreter use and also investigated factors related to the use of ad-hoc interpreters.14 The most significant factors related to the likelihood of using ad-hoc interpreters included wait times for a professional interpreter and locating a professional interpreter.14 Among doctors, nurses, and social workers completing a self-administered questionnaire in a Swiss study, 66% preferred the use of ad-hoc interpreters, compared to 34% preferring professional interpreters.46 Those preferring ad-hoc interpretation services did so mainly due to easy access and practical advantages, such as immediate availability.46
The reasons for continued use of ad-hoc interpreters were further analyzed in a study using focus groups consisting of practitioners. The study investigated approaches in communicating with LEP patients and the associated constraints in providing these services in a private practice.25 In the study, ad-hoc interpreters were the most common form of interpretation used.25 The clinicians who used ad-hoc services noted that reasons
culture.25 Practitioners who had experience with telephone interpreter services in the past
appreciated access to professional interpreters in multiple languages, however they also expressed concern regarding the inconvenience and extra time involved.25 Despite clinicians use of ad-hoc interpreters in this study, they admitted to having concerns about inaccuracy and incompleteness of interpretation.25 Almost all clinicians showed concern for quality of patient care for LEP patients and the potential inability to obtain an
accurate medical history.25
Overall, the use of professional interpreters is associated with improvements in clinical outcomes and patient satisfaction than other interpretation methods.7 LEP
patients demonstrated equal adherence to follow-up after emergency department visits as English-proficient patients when professional interpreters were used.47 One study found a
statistically significant increase in preventative services among LEP patients who used a professional interpreter compared to no interpreter use.48 While issues of time constraint and limited availability of the professional interpreters are barriers for healthcare
professionals, communication without professional interpreters negatively impacts LEP patients. Several QI studies attempted to overcome these issues in an attempt to increase professional interpreter use.
Prior Interventions to Increase Professional Interpreter Use
A common finding in several prior studies is the underuse of professional interpreters despite the growing evidence that use of professional interpreters result in higher quality care. Few quality improvement intervention studies have been performed
to increase use of professional interpreters, largely due to the financial costs to implement these interventions.3,16 One QI intervention sought to increase rates of language services used at a hospital with a robust language access services.16 The intervention targeted healthcare professionals involved in patient care and consisted of education, EMR alerts, and phone equipment upgrades.16 The study was a 3-month intervention and data was collected during those three months, as well as 12 months prior to and after the intervention.16 Overall, they found that the intervention was associated with fewer interpreter-related delays in care, decreased ad-hoc interpreter use, and increased professional interpreter use.16 The study found a baseline rate of telephonic
interpretations per patient-day of 0.38 prior to intervention, no significant change during the intervention, and an increase of 0.2 post-intervention, a 53% increase from baseline.16
The rate of total overall interpretations (in person and telephone) similarly increased in the year post-intervention by 54%, indicating an increase in in-person interpretation as well.16 Although the authors of the study deemed the intervention successful, the intervention was unable to reach the hospital’s minimum goal of 2 interpretations per patient-day despite the large multi-disciplinary intervention.16
Prior studies have demonstrated that use of professional interpreters with LEP patients during discharge was associated with adherence to discharge instructions equal to English-proficient patients, as well as a comparable understanding of the instructions.40 A recent study explored the effects of bedside telephone interpretation during hospital discharge preparedness among LEP patients.17 In order to eliminate the clinician-reported
access to professional interpreters. Although the study found an improvement in understanding of medication purpose, they found no significant change in overall measures of discharge preparedness with the implementation of bedside telephone interpreter use.17 From focus groups, they found that bedside phone interpretation was helpful for improving clinical communications in some aspects, especially for pain management and simple decision making with patients, but there was infrequent use of the phones for discharge counseling.17 Instead, clinicians preferred in-person interpreters and direct communication with family members for discharge counseling.17 Providing healthcare professionals rapid access to professional interpreters by phone alone is not an adequate means to increase use.
In a similar study, the impact of bedside telephone interpreter services on
comprehension of informed consent among LEP patients was assessed by installing dual-handset phones at every bedside which enabled 24-hour rapid access to professional interpreters.18 This study found a significant improvement in patient-reported informed consent, although the use of ad-hoc interpreters remained unchanged with about one-third of patients continuing to use ad-hoc interpreters.18 This suggests that increased rapid
access to professional interpreters alone is likely not sufficient to increase comprehension and decrease ad-hoc interpreter use.18 Changing the culture of ad-hoc interpreter use has been refractory to existing intervention studies and other approaches are likely required.
Another quality improvement study assessed the effect of screening patients for language preference early in care on professional interpreter use in ten hospitals.49
in-person interpreters to be called ahead of time.49 Other strategies were also
implemented at the same time, including targeted education efforts to hospital staff and clearly articulated support from executive leadership.49 The results showed the majority of hospitals showed an improvement in professional interpreter use by at least 5%. However, they found that five of the hospitals demonstrated a decrease in professional interpreter use for some period of time during the intervention.49 The authors noted that
this was not a result of changes in staff or language services and likely reflected a better measurement of actual delivery of services.49 Identifying the need for an interpreter is not enough to prompt professional interpreter use.49 The authors stated that the delivery of language services is largely dependent on physicians, nurses, other hospital staff, and patients request.49
A possible explanation for the refractory rate of professional interpreter use is that the cause is multifactorial. Most prior studies focus on healthcare professionals’
perspective and reasons for low professional interpreter use. A majority of the prior interventions have targeted those reasons and relied on hospitals and healthcare professionals to change the practice and culture of interpretation use. However, few studies have focused on patients’ perspective and the potential patient barriers of
professional interpreter use. Therefore, there are very few interventions that target these potential patient barriers.
Existing Research on Patient Knowledge and Perspective
While it is important to investigate the opinions and preferences of healthcare professionals regarding professional interpreter use, it is also essential to explore the perspective of LEP patients. This may uncover factors that are possibly preventing
substantial changes in professional interpreter use. There is a large research gap regarding patients’ perspectives and how knowledgeable patients are about the extensive research performed on language barriers.50
One study analyzing the pattern of interpreter use in a hospital found that 93% of hospitalized LEP patients preferred to use a professional interpreter when communicating with a physician and 73% also preferred to use an interpreter when interacting with nurses.9 However, only 43% of LEP patients reported that they were asked if they needed
a professional interpreter since their admission.9 Baker et al. also found in their study that about one quarter of LEP patients in their study felt that professional interpreters should have been used during encounters with healthcare professionals, especially during encounters when healthcare professionals used their own limited second language skills to communicate.51 Use of a professional interpreter often depends on the initiation by a
healthcare professional, even if patients feel that a professional interpreter is needed.45 These findings suggest that patients want to use professional interpreters more than the current usage rate.
Some research has found a few barriers for lack of professional interpreter use. One common barrier for poor use of interpreters was patients’ overestimation of their English language communication abilities.52 A study in an emergency department
demonstrated that only about 20% of LEP patients with deficient comprehension of discharge instructions were able to self-perceive their lack of understanding.10 On the other hand, clinicians rarely confirm what patients actually understand and may overestimate their clarity.11 Subjective measures of patient comprehension by both the patients and the clinicians are often overestimated and this is a potential reason for continued low professional interpreter use.
A recent study by Schwei et al. further investigated patients’ perceptions of when professional interpreters are needed.19 The study identified two factors that influenced when LEP patients determined professional interpreters were necessary: their self-identified level of English proficiency and the anticipated complexity of communication during their healthcare encounter.19 Given that these measures are subjective and can be
easily over- or under-estimated, it is questionable whether objective measures should be provided to determine if a professional interpreter is needed. However, this method would take away patients’ autonomy and taking away patient preferences will lead to decreased patient satisfaction.53 The study concluded that the healthcare system need to place more effort into LEP education and stress the importance of utilizing interpreters in all encounters.19
Another patient barrier involved the fear of disclosing limited English skills and lack of empowerment to request an interpreter.52 Dunlap et al. studied the effects of language concordant care on patient satisfaction and discussed how many LEP families did not feel empowered to request an interpreter for health-related information.54 The
admit their inability to understand their English-proficient medical team.54 Focus groups
led by the US Maternal and Child Health Bureau also found that LEP families were often reluctant to ask questions or make suggestions in health care settings.55 Despite patients’ desire for an interpreter, they are often unable to self-advocate for a professional
interpreter.
Prior studies have shown that patient education can increase self-advocacy behavior.56–58 A study by Sriphanlop et al. performed a patient activation intervention to assess if an educational handout given to patients in a waiting room would activate patients to self-advocate for colorectal cancer screening.56 The study indicated that patient education is effective at prompting patients to discuss colorectal screening with clinicians, from 8.3% to 23.5%, and increase screening rates.56 Another study examined
the impact of patient education on patients’ behavior in a primary care setting and concluded that patients who received information leaflets displayed behavior closer to that recommended by guidelines for gastroenteritis and tonsillitis.59 71.8% of patients in this study who received the leaflet followed the recommended guidelines compared to 43% of patients who did not receive the leaflet.59 Lack of self-advocacy may be an
important reason why professional interpreters are not used often and education for LEP patients may help them initiate interpreter use.
Very little is known about the amount of knowledge patients have regarding the negative effects of language barriers and benefits of professional interpreter use.9,50,60 One study found that the majority of participating LEP patients are unaware that patients have the legal right to have professional interpretation at no cost.60 Patients need to be
better educated about their rights, as often the patient may be the only one who realizes that an interpreter is necessary.16 Healthcare professionals may not ensure that patients understand the advantages of professional interpreter use and may assume that patients prefer to have family members interpret.53 It is only after the patient is informed that the patient can decide what type of interpreter they prefer.53 Although several studies acknowledge that not much is known about patients’ knowledge and perspectives on language barriers and professional interpreter use, they stress the importance of patient education in the decision-making of professional interpreter use.
There are very few studies that assess patient knowledge regarding negative effects of language barriers and benefits of professional interpreter use. There are no existing interventions that use patient education as a tactic to increase professional
interpreter use. Several studies have stressed the importance of patient education, yet they failed to assess the extent of patients’ knowledge.16,19,53 This research gap needs to be further explored to identify the barriers to poor professional interpreter use from the patient’s viewpoint.
METHODS Study design
The study will be a non-randomized trial. The purpose is to assess if providing an educational survey regarding interpreter use before the patient encounter will be
associated with an increase in professional interpreter use. The study will consist of two consecutive three-week periods with a control group and an intervention group. During the first three weeks, patients will be recruited into the control group to determine the baseline proportion of interpreter use prior to the intervention. During the second three-week period, patients will be recruited into the intervention group.
Recruitment, study population and sampling
Patients will be recruited from the Boston Medical Center family medicine clinic. The outpatient setting will allow us to assess the consequence of the survey on one patient encounter. This setting will also allow exposure to a wide variation of patients with varying medical complaints, from acute to chronic problems, simple to complex diagnoses, and new to established visits. In general, specialty clinics may have different rates of interpreter use due to the nature of diagnoses; thus, we chose a general medicine practice for the broader range of diagnoses. Patients may only be recruited to one study arm only. If a patient in the control arm has a follow up appointment during the
recruitment period for the intervention arm, that patient will be excluded from the intervention arm.
The family medicine clinic reports caring for about 2500 patients per month, 50% whom are Spanish-speaking. The electronic medical record program used by this clinic requires all patients to choose a language preference as part of their demographic sheet. Study research assistants will have access to this information. Patients who list a
preference for Spanish in their medical records and have scheduled appointments during the study period will be recruited. Potential participants will be ineligible for the study if they are unable to give informed consent or have a diagnosis of dementia.
Given an alpha of 0.05, beta of 0.2, proportion of professional interpreter use in the control group of 0.4, and proportion in the intervention group of 0.5, 387 patients in each arm of the study are needed.61 The proportions were based on the outcome of prior studies that measured professional interpreter use prior to and after an intervention.16 We
chose a 3-week period for each study arm to minimize the effect of seasonal variations in patient populations and diagnoses. Using the three-week time frame, there will be about 937 patients who may be eligible to participate in each study arm.
Bilingual Spanish-speaking clinicians will be excluded from this study.
Treatment (or intervention)
The intervention is a brief survey (Appendix 1) in Spanish that patients will complete on an iPad prior to their appointments. The survey will serve as both a patient education tool as well as a means to capture data regarding patients’ knowledge of professional interpreter services. The survey will consist of six yes-or-no questions
asking patients if they are aware of findings from existing research regarding language barriers and interpreter use.
The surveys will be translated into Spanish and will be piloted in focus groups with participants proficient in both English and Spanish, in order to make sure the questions are clear and understood by the target population.
Study variables and measures
The primary outcome is the self-reported professional interpreter usage using a post-appointment survey. The secondary outcomes include the results of the pre-post-appointment survey elucidating patients’ knowledge of effects of language barriers and benefits of professional interpreter use. Another secondary outcome will be the reasons why patients do not use an interpreter.
Data collection
After Spanish-speaking patients check into their appointments, they will be asked for consent to participate in this study. After providing written consent, they will receive the pre-appointment survey intervention on an iPad if they are in the intervention group. If not, they will proceed to their appointment in the usual fashion. Immediately after the appointment, both the control and intervention patients will be asked to fill out the post-appointment survey (Appendix 2) on an iPad, regarding interpreter use during their appointment.
Data analysis
The results of the pre-appointment survey, which assesses knowledge about professional interpreters, will be reported as the percentage of patients that answered “yes” to each of the questions. The responses to question 2 of the post-appointment survey, which are reasons for not using a professional interpreter, will be reported as percentages.
The results of professional interpreter use from the post-appointment survey will be analyzed using Chi-square analysis to determine if there is a statistically significant difference between the two study arms. Stratified analyses will be performed to adjust for age and sex.
A sub-group analysis will then be performed using Chi-square analysis to
determine if there is an association between failing the educational survey and interpreter use. The median score of the educational survey will be used to determine a passing score. The scores at or above the median will be considered passing, whereas the score below will be considered failing.
Timeline and resources
During the summer of 2018, we will submit our study protocol to the IRB for approval. We will hire and train two Spanish-proficient research assistants to administer the pre- and post-appointment surveys. The pay rate will be about $15 per hour. The two surveys will also be translated into Spanish and piloted in a focus group. A technician
will be hired to upload the questionnaires onto two iPads. A statistician will be hired for data analysis.
We anticipate recruitment for the study in September to October of 2018. Data analysis will begin after the study period ends and take about 1 week.
Institutional Review Board
The study protocol will be submitted to the Institutional Review Board (IRB) of the Boston University Medical Center because our study involves intervention with human subjects and require access to patient information. Approval from the IRB will be obtained before subject recruitment.
CONCLUSION Discussion
The results of the study may indicate that the educational survey is associated with increased professional interpreter use. However, there is a possibility that the survey may serve as a reminder for patients to ask for an interpreter rather than an educational tool. Alternatively, the survey may also provide patients a sense of empowerment to request a professional interpreter. The subgroup analysis will determine if patients who failed the educational survey are associated with increased interpreter use. If there is an association, it may indicate that the survey acted as an educational tool rather than a reminder, although the element of empowerment cannot be ruled out as well. The reverse association would indicate that passing the passing the survey is associated with
interpreter usage.
Several studies have shown that patient education tools can successfully prompt desired patient behavior, such as increasing cancer screening rates.56–58 Patient education on language barriers and interpreter use may change patients attitudes and allow them to self-advocate for professional interpreter use if is not initiated by healthcare
professionals. The impact of this study may provide evidence for future interventions to educate patients on language barriers and professional interpreter use. This may allow patients to make well-informed decisions about whether or not they need a professional interpreter.
There are several potential limitations to this study design. One limitation of the study is the inclusion criteria do not use an objective measure of English proficiency. An
inclusion criterion, a listed preference for Spanish in the medical charts, may recruit patients with a high level of English-proficiency and potentially weaken a possible association of patient education and interpreter use. However, the survey results provided by any bilingual English-proficient participants should not be affected by their
proficiency. A second limitation is the self-reported data will be subjected to limitations of comprehension and recall. Piloting the surveys prior to the intervention will minimize the effects of comprehension. The surveys will also not reveal the number of times patients have encountered the healthcare system. Those with more encounters are more likely to have exposure to and knowledge of professional interpreter use than those without usual care. Another limitation is recruitment from only one clinic with a
relatively high percentage of Spanish-speaking patients. It is possible that the patients at this clinic have a higher level of awareness of professional interpreter use and a higher baseline of use than other clinics. A well-established culture surrounding interpreter use may already exist in this clinic and may lead to less compelling results compared to what would be found in a clinic with poor culture around interpreter use.
Another limitation is that patients will not be randomized for logistical reasons. This may threaten the internal validity of the study. To mitigate these effects, we will statistically control for possible confounders such as age and sex. Clinicians will also be blinded during the study. Using a family medicine clinic for patient recruitment is another limitation. Patients may already have good rapport with their healthcare professionals in the clinic and may have already settled on a method for interpretation. A final limitation is that interpreter use will only be measured once immediately post-intervention. It is
unknown if the same proportion of patients who receive the intervention will request an interpreter at their next visit. Further studies will need to be performed to assess the long-term effects of patient education strategies.
Despite these limitations, our findings will identify if there is a lack of patient knowledge, which has been suggested in prior studies. Although healthcare professionals are aware of the effects of language barriers and the need for professional interpreter use, it is possible that they are not making patients aware of this information, especially when determining if a professional interpreter is necessary. Patients in this study may be more aware of this information because they are in a high LEP-population setting where healthcare professionals are experienced with caring for them. LEP patients in medical settings with a smaller LEP patient population and fewer language service resources will likely to have a larger knowledge gap. Regardless, these results are still generalizable to the rest of the LEP patients, as it will likely indicate a gap in knowledge exists. The gap may differ in size depending on the healthcare setting, however the size will not alter the importance of patient education.
We believe that a lack of patient knowledge is a barrier for professional
interpreter use. If an increase in professional interpreter use is found in the intervention group, future studies can further assess the impact of patient education on the rate of professional interpreter use. Even if lack of patient knowledge is not associated with professional interpreter use, patients are entitled to know how language barriers can affect them and the research indicating that professional interpreter use is the best
approach to overcome language barriers. Patients deserve to make an informed-decision regarding interpreter use.
Summary
There is a significant healthcare disparity among LEP patients due to language barriers. Several negative healthcare outcomes are associated with language-discordant interactions and overcoming these barriers has garnered the medical community’s attention.6,12 Professional interpreter use provides language concordant care and
improves overall quality of care for LEP patients.7 Although healthcare professionals are aware of the association between professional interpreter use and improved healthcare quality and outcomes, it is unclear whether LEP patients are aware of the research
findings.13 Very few studies have explored the patients’ perspective on and knowledge of professional interpreter use.
Our study focuses on this research gap and will determine if there is a lack of patient knowledge and whether this is associated with poor professional interpreter use. The medical field is emphasizing a patient-centered model of care, where LEP patients are no longer bystanders and become active participants in the treatment they receive. However, LEP patients may not feel empowered to request an interpreter in order to play that active role or lack the knowledge to make an informed decision about using an interpreter. This lack of empowerment and knowledge can result in poorer understanding of health issues and inhibit patients from participating in decision-making. It will also lead to poor adherence to treatment plans and decreased patient satisfaction.53 If patients
are aware of the important research regarding language barriers and professional
interpreter use, perhaps it will empower them to request a professional interpreter when they feel one is needed and become an equal and active part of medical teams.
Clinical and/or public health significance
Patient education is a well-studied topic in the medical field. Existing successful education tools may be able to be applied to LEP patients in order to decrease their knowledge gap and increase professional interpreter use. Increasing language-congruent interactions will decrease healthcare disparities, increase patient comprehension and satisfaction, and improve quality of care.40,46,54 LEP patients need to recognize that language barriers place them at a disadvantage which can be eliminated through the use of professional interpreters. If not, the growing LEP population will continue to suffer the effects of language barriers. Overcoming these barriers will positively influence
healthcare outcomes and ensure LEP patients receive safer and more equitable health care.
Language barriers have a major impact on the cost of healthcare for LEP patients. Professional interpreter use is shown to increase use of preventative services and
physician visits.62 Increased professional interpreter use also leads to increased use of preventative services, fewer emergency department visits, lower costs of diagnostic testing and hospital admissions.43,63 All of these will in turn reduce financial costs and decrease unnecessary resource utilization. Research also shows that the cost of providing language services may be recouped through shorter visits, improved compliance, and
reduced testing.64 One study estimated that the cost of interpretation services costs about
0.5% of the average cost per medical visit.65 LEP patients in the ED who use professional interpreters also have fewer tests, medications, intravenous catheter placements as well as lowest overall charges.64 Increasing the use of professional interpreter use will not only improve healthcare quality, but will also decrease the financial burden of caring for LEP patients.
APPENDIX 1
Professional Interpreter: Medical interpreters who are trained to accurately translate medical terminology
• Did you know that patients who do not speak or understand English well are at higher risk for medical complications compared to English-speaking patients?
o 1) Yes 2) No
• Did you know that using a professional interpreter is the best way to interact with your healthcare providers if you do not speak or understand English well?
o 1) Yes 2) No
• Did you know hospitals and medical offices are required to provide professional interpreters if you need one?
o 1) Yes 2) No
• Did you know professional interpreters are always free of cost for you in any hospital or medical office?
o 1) Yes 2) No
• Did you know that research shows using professional interpreters improve the quality of care you receive and lead to better health outcomes?
o 1) Yes 2) No
• Did you know that using friends and family to interpret often have significantly more errors in translation and increases the risk of medical complications than when using a professional interpreter?
APPENDIX 2
Professional Interpreter: Medical interpreters who are trained to accurately translate medical terminology
• Did you use a professional interpreter provided by the clinic? o 1) Yes 2) No
• If a professional interpreter was not used, why? o 1) Attempted to get interpreter but failed
2) Preferred not to use interpreter 3) Used family or friend to interpret 4) Clinician did not ask 5) Other reason. Please Describe:
LIST OF JOURNAL ABBREVIATIONS
Acad Med Academic Medicine
Am J Public Health American Journal of Public Health Ann Emerg Med Annals of Emergency Medicine
Arch Pediatr Adolesc Med Archives of Pediatrics and Adolescent Medicine BMC Health Serv Res BMC Health Services Research
Health Aff Health Affairs
Health Commun Health Communication Health Serv Res Health Services Research
Hisp Health Care Int Hispanic Health Care International Int J Nurs Stud International Journal of Nursing Studies
Int J Qual Health Care International Journal for Quality in Health Care JAMA Journal of the American Medical Association J Gen Intern Med Journal of General Internal Medicine
J Healthc Qual Journal for Healthcare Quality
J Health Care Poor Underserved Journal of Health Care for the Poor and Underserved
J Hosp Med Journal of Hospital Medicine J Pediatr Surg Journal of Pediatric Surgery Med Care Medical Care
Med Care Res Rev Medical Care Research and Review Milbank Q The Milbank Quarterly
N Engl J Med New England Journal of Medicine Patient Educ Couns Patient Education and Counseling Pediatr Emerg Care Pediatric Emergency Care
Perm J The Permanente Journal
Proc Natl Acad Sci USA Proceedings of the National Academy of Sciences of the United States of America
R I Med J Rhode Island Medical Journal Telemed J E Health Telemedicine Journal and e-Health World J Urol World Journal of Urology
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