A study published in the June issue of the Journal of Racial and Ethnic Health Disparities joins a well-established chorus: Primary care practices and patients benefit from robust access to professional medical interpreters, yet their use continues to be limited.
The authors found that having medical assistants screen for patients who could benefit from a PMI and then arrange to have one ready by phone as soon as the clinician entered the exam room helped. But they also uncovered barriers related to workload, time and cost that remained under such a protocol.
Better access to PMIs "may be an effective means of improving patient satisfaction and communication, and thereby improving health disparities related to language," the authors wrote in "Identifying and Addressing Language Needs in Primary Care: a Pilot Implementation Study."(doi.org)
It's a booming need. The number of people in the United States with limited English proficiency is expanding faster than the general population. In 2013, 8.5% of the U.S. population met LEP criteria(www.migrationpolicy.org) -- a population segment that authors of the recent study compare to the 9.5% of Americans who have diabetes.
- A study published in the June issue of the Journal of Racial and Ethnic Health Disparities identifies several complexities in implementing a medical translation protocol.
- Telephone translation sometimes added time and uncertainty to the primary care rooming process.
- Authors noted that the number of people in the United States with limited English proficiency is expanding faster than the general population.
"Having LEP is associated with disparities in health care access, satisfaction with care and communication, receipt of preventive care, receipt of health education, blood-pressure control and risk of drug complications," the authors wrote. "Yet, professional medical interpreters are underused."
The protocol was tested in a pilot at two clinics in an urban safety-net hospital, and data collected was compared with that for four other clinics at the hospital that did not use the protocol.
MAs at the pilot clinics were trained to ask all patients what language they spoke at home, followed by three more questions for those who named a language other than English:
- What is your preferred language to use for your visit today?
- How well do you speak English (very well, well, not well or not at all)?
- What is your preferred language for written health care information?
For patients who preferred a non-English language and those who answered anything other than "very well" to the second question, the MAs were to get a PMI on the phone during the rooming process before the clinician arrived.
The six clinics had similar patient populations, were located in the same building and had dual-handset interpreter phones in every exam room. Each clinic had 10 to 12 attending physicians and nurse practitioners and "approximately three MAs." About one-third of the patients had LEP and primarily spoke Spanish, Haitian Creole or Cape Verdean (Portuguese Creole).
The researchers conducted pre- and postimplementation surveys with questions about the clinicians' clinical experience, second-language skills, use of interpreters and confidence in communicating with patients with LEP, among other topics. They also interviewed participants two to four months after the protocol was implemented.
What they found: Adding PMIs, particularly when face-to-face interpreting is unavailable, is a complex process -- more so than they had anticipated.
Barriers and Benefits
Adding an unexpected variable, the medical center changed its primary telephone PMI vendor about six weeks before the study commenced.
"This transition was unrelated to the current project, but its negative impact was an important theme discussed by nearly every participant," the authors wrote. Clinicians said difficulties with the speakerphone option often forced them to try to use the unwieldy handsets instead, and they noted that the system's menus were cumbersome.
"In addition, interpreters were sometimes not available in patients' languages, leading to delays in care. Providers even described the interpretation provided by the new vendor as 'slow' and of 'questionable' quality. Because of these issues, providers wanted to avoid using the telephone interpreters."
Participants also said the protocol affected workflow.
"Some MAs knew their providers' workflows well, and this facilitated their efforts to call the interpreter," the authors wrote. "However, if MAs knew a provider frequently ran late, this knowledge could serve as a barrier to calling an interpreter; MAs knew it might be too difficult to time the phone call appropriately and so would not try."
MAs and clinicians also expressed concern about the cost of keeping an interpreter on the phone while waiting for the clinician to enter the room.
The professional culture of MAs -- especially their role as patient advocates -- "may also impact language screening," the authors wrote.
"When patients request an interpreter, MAs can advocate for patients by calling an interpreter. But when patients want to speak English despite having LEP or want to use family members to interpret, the protocol specified that MAs should arrange for a PMI, even though this was not the patient's preference.
"This potential conflict between the protocol's instructions and patients' expressed preferences may have contributed to MAs' lack of endorsement of language screening."
Despite these challenges, patients generally had positive response to the protocol and clinicians also saw benefits.
Among clinicials who implemented the protocol, satisfaction in the quality of care they provided to patients with LEP increased from 44% before implementation to 83% after, and satisfaction with communication increased from 55% to 83%.
The authors said clinicians also noted that having an interpreter on the phone as soon as they walked into the exam room "positively changed the tone of the visit by eliminating the awkward minutes of contracting interpreter services at the start of visits. They could jump right into conversation instead of waiting silently while dialing."
Ultimately, the authors concluded that the inconsistencies of equipment and culture in their protocol underscore the variety and significance of translation barriers in primary care.
"While we faced challenges with successful implementation of the rooming protocol," they wrote, "our findings open the door for further research on structural cultural competence interventions to improve use of available language assistance tools.
"Additional interventions, such as electronic alerts to interpreter services to trigger an in-person interpreter, protocols designed to trigger the availability of video interpreter devices, and formal language assessment of patients and providers should be studied to understand if these interventions have the potential to improve language-related health disparities."
Noting that health systems have existing guidelines for screening patients' language needs, the authors called for further research "to improve language screening questions and procedures." They concluded by offering three broad recommendations for practices attempting to update translation procedures:
- Carefully implement any changes that might impact patient care, paying particular attention to potential challenges and consequences.
- Consider the professional culture and cultural background of all members of the health care team, as well as their professional relationships to each other.
- Capitalize on the motivation to improve patient care and communication while controlling costs.
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