Cultural and Linguistic Competencies: Language Access and Interpreter Issues

LANGUAGE ACCESS AND INTERPRETER ISSUES
Though linguistic competency is not the only facet of cultural competency, discussions of cultural competency tend to focus on language access issues, or linguistic competency, primarily because 1) communication and culture are integrally linked and 2) language is the only facet of cultural competency based in law. The U.S. Department of Health and Human Services has long considered providing language assistance a key component of Title VI of the Civil Rights Act of 1964, specifically, the clause that prohibits discrimination based on national origin. Frequently, health and social service agencies have provided suboptimal language assistance for their clients with limited English proficiency (LEP). Research has demonstrated that reliance on ad hoc interpreters, family, friends or the provider’s own poor language skills can result in negative outcomes for the client-provider relationship and undermines confidentiality, client satisfaction with services, access to mental health services, the ability to adhere to recommended treatment regimens and participation in preventive services. This section of resources includes the federal mandate for language access as required by the Civil Rights Act. Also included are resources that provide strategies for reducing language barriers and for ensuring culturally and linguistically appropriate services in health care settings.

Change PH, Fortier JP. Language barriers to health care: An overview. Journal of Health Care for the Poor and Underserved. 1998;9:S5-S25.

This article provides a context for the discussion of language access in health care by reviewing federal and state laws and related initiatives, and discussing the case history of language access in Seattle, Washington. Additionally, it describes different models for providing language services (e.g., interpreter banks, translator pools, cultural advocates). Finally, it discusses delivery, financing and regulation of language services in managed care environments.
Ferguson WJ, Candib LM. Culture, language and the doctor-patient relationship. Family Medicine [serial online]. 2002;34(5):353-361. Available at: http://www.stfm.org/. Accessed May 18, 2007.

This article reviews the literature on the doctor-patient relationship and communication to determine how differences between providers and patients in race, ethnicity and language influence the quality of their relationship. Twenty-one articles were found and divided into: 1) outcome studies with limited English-speaking versus English-speaking patients; 2) studies of strategies that improve outcomes with patients who speak limited English; 3) studies of physician bias, rapport-building and patient preference, with race and ethnicity as variables and 4) studies on relationship-building with race and ethnicity as variables. The review provides evidence that race, ethnicity and language all influence the quality of doctor-patient relationships. African American and Hispanic patients, especially those with limited English, are less likely to engender empathetic responses from doctors, establish rapport with doctors or receive sufficient information and encouragement to participate in medical decisionmaking. Minority patients are more likely to choose providers of the same race, ethnicity or language and also more likely to be satisfied, connected and involved in decisionmaking with such providers.
Office for Civil Rights. Title VI of the Civil Rights Act of 1964; Policy guidance on the prohibition against national origin discrimination as it affects persons with LEP. Federal Register: U.S. Department of Health and Human Services. 2000;65(169). Available at: http://www.hhs.gov/ocr/lep/guide.html. Accessed May 18, 2007.

This policy guidance clarifies the responsibilities of health and social service providers that receive financial assistance from the U.S. Department of Health and Human Services (DHHS) and provides guidance for fulfilling those responsibilities under Title VI of the Civil Rights Act of 1964. The policy guidance reiterates DHHS’ longstanding position that, to avoid discrimination against LEP persons on grounds of national origin, health and social service providers must take adequate steps to ensure that such persons receive, free of charge, the oral and written language assistance necessary to afford them meaningful access to services. The policy guidance specifically states that use of family members and friends as interpreters is not considered an adequate means of guaranteeing such access.
? Office of Minority Health. National standards for culturally and linguistically appropriate services (CLAS) in healthcare: Final report. Washington, DC: U.S. Department of Health and Human Services; 2001. Available at: http://www.hablamosjuntos.org/pdf_files/. Accessed May 18, 2007.

With input from a national advisory committee of policymakers, health care providers
and researchers, these 14 standards were developed based on an analytical review of key laws, regulations, contracts and standards currently in use by federal and state agencies and other national organizations. The standards were created to ensure that all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner.
? Perkins J, Simon H, Cheng F, Olson K, Vera Y. Ensuring linguistic access in health care settings: An overview of current legal rights and responsibilities. Los Angeles, CA: National Health Law Program for the Henry J. Kaiser Family Foundation; 2003. Available at: http://www.kff.org/uninsured/. Accessed May 18, 2007.
 
This manual provides an overview of the status of linguistically appropriate access to
health care and the array of national and state legal requirements, as well as accreditation agencies, affecting the delivery of linguistically appropriate services to non-English speaking patients. Recommendations include: educating health administrators and providers about the laws related to linguistic access, strengthening monitoring and enforcement of the laws, collecting data on the health status and health care utilization of patients with limited English proficiency and hiring bilingual staff and interpreters.
Riddick S. Improving access for limited English-speaking consumers: A review of strategies in health care settings. Journal of Health Care for the Poor and Underserved. 1998;9:S40-S61.

Written by one of the leaders in the language access movement, this paper describes different strategies developed to provide health care services to patients with limited English skills. Some of these strategies include: hiring bilingual/bicultural providers, creating an outreach position for the minority population, using bilingual employees as interpreters, hiring or contracting professional interpreters, using bilingual volunteers, etc. The paper also discusses new approaches being used in medical interpreting, such as remote-simultaneous interpretation, remote-consecutive interpretation, video conferencing and software programs. The author explains how various health care settings are applying these strategies in their daily functions.
? Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch G. Language barriers in medicine in the United States. Journal of the American Medical Association. 1995;273(9):724-728.

This article reviews the status of interpreter services in the U.S. health care system and the legislative responses to meet the needs of patients with limited English proficiency. Providers frequently rely on three suboptimal mechanisms for interpretation: 1) their own language skills, 2) the patient’s family or friends or 3) ad hoc interpreters (e.g., other patients in waiting room). These mechanisms can compromise information transfer, undermine patient confidentiality and informed consent, disrupt the provider from the clinical evaluation and increase frustration for both providers and patients. Federal policies (i.e., the Civil Rights Act) have been created to ensure equal access; however, these policies are vague and unfunded and rely on ad hoc enforcement. Recommendations for improving interpretation in health care include: development of clear standards for medical interpreter training and certification; training appropriate ad hoc interpreters (i.e., bilingual staff); contracting with telephonic interpretation services and having multilingual literature, videos and signage available. Additionally, the authors encourage increasing the recruitment of multilingual persons to the health care work force and teaching English to patients with limited English proficiency.

Woloshin S, Schwartz LM, Katz SJ, Welch HG. Is language a barrier to the use of preventive services? Journal of General Internal Medicine. 1997;12:472-477. Available at: http://www.pubmedcentral.nih.gov/. Accessed August 14, 2007.

This article describes a study that found that women in Ontario, Canada who spoke a language other than English at home were less likely to receive preventive services (i.e., breast examinations, mammograms and Pap tests). Even with the presence of universal and comprehensive insurance in the Canadian health care system, and controlling for variables known to be related to the utilization of preventive services (e.g., education, income, family size, number of doctor visits, ethnic self-identification and immigration status), language was significantly related to fewer breast exams, Pap tests and mammograms.

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