Interpreter – Provider Partnerships: Why Are They Important?

Presentation to the International Medical Interpreters Association (IMIA) 2007 Conference Christina Facchina Fluet, MPH, CI, CT October 7, 2007 Boston, MA

Welcome and Introductions   Who I am Who are you?

 Foreign language interpreters?

 ASL interpreters?

 Primary practice = medical settings?

 Interpreter service coordinators?

 Health care administrators?

 Came to interpreting from a health care profession?

THE MAKING OF A MEDICAL INTERPRETER

Part 1: Ignorance is bliss?

 Novice interpreter in medical settings – how did I get there?

 What I don’t know, CAN hurt me - and others:  effects of miscommunication, provider perceptions, legal ramifications, my own biases

Part 2: Wrong place - wrong skills    Quickly learned that this is bad combination Lacked conceptual framework to fully understand why I felt - and was incompetent Decision: Take a hiatus……

Part 3: Let’s try again    That which we resist the most presents the greatest lessons Consumer as ally, teacher, and colleague Continuing education:  Medical and interpreting trainings & classes; talk with other interpreters; talk with providers; mentor; read and listen, e.g., the waiting room as teacher

Part 4: Success?

 Medical interpreting became one of my primary areas of specialty

What changed?

FOR DISCUSSION:

What has been your evolution as a medical interpreter?

OR, if you are an administrator, has your view of the value and/or importance of medical interpreter services changed over time?

FROM INTERPRETING TO PUBLIC HEALTH …

WHAT DO WE KNOW ABOUT THE RELATIONSHIP BETWEEN INTERPRETERS AND HEALTH OUTCOMES?

Background - 1  Dramatic improvements in health outcomes are not shared equally by all Americans, e.g., life expectancy, diabetes, cardiovascular disease, asthma, cancer, HIV/AIDS  Minority Americans fair worse in both health outcomes and access to and utilization of health care services

Background - 2

Contributing factors:  Social determinants: education, SES, housing, environmental hazards, occupational hazards, racism   Lack of access to care: uninsurance, underinsurance Even for those with access (insurance), lower quality of care (disparities) still exists for minorities

What other factors contribute to health disparities?

Background - 3 In 1999, Congress commissioned Institute Of Medicine (IOM) to study health disparities among racial/ethnic minority groups Result: IOM Report and Recommendations, “Unequal Treatment” (see www.nap.edu

) Since then, rich body of work examining health disparities and factors that contribute to them

Background – 4 Beyond social determinants and insurance, other factors that play a key role:  Limited English Proficiency (LEP)  Language and cultural concordance between provider and patient  Culturally competent care  Use of professional interpreters

FOR DISCUSSION: Why is it important to understand the public health context for interpreter services?

As an interpreter?

As an Interpreter Services Coordinator?

As a Health Care Administrator?

Some Possible Reasons: Understanding the evidence-based relationships between language interpreters health outcomes (health status, chronic disease) health services (cost, utilization) i.e., understanding the “business case”

Some Possible Reasons:  Understanding providers’ and payers’ perspective - speaking their language

Some Possible Reasons:  Greater appreciation for what interpreters do and the power they hold in the medical setting  Can you think of others?

Adding to the evidence: MGH Language Concordance Project Center for Child and Adolescent Health Policy Massachusetts General Hospital Funded by the Deborah Noonan Foundation

MGH Language Concordance Project OUR INTEREST: The health of Latino children Poorer overall health status Higher rates of morbidity Poorer access to care (e.g., uninsurance, underinsurance) Higher rates of unmet need Lower rates of health service utilization (e.g., well child care)

MGH Language Concordance Project Research Questions: Is the quality of well child care for Latino children affected by: language concordance between parent and provider?

use of interpreters?

provider’s self-rated cultural competence?

MGH Language Concordance Project Design: 2006 Cross-sectional survey of parents (n=462) and pediatricians (n=22) in three culturally diverse urban (Boston) health centers between January 2006-March

MGH Language Concordance Project Parent Measures: “Promoting Healthy Development Survey (PHDS)”:   Assesses specific aspects of well-child care outlined by the American Academy of Pediatrics and the Maternal and Child Health Bureau Measures “quality of care” (QoC) - preventive and developmental care

MGH Language Concordance Project Parent Measures: care:      Aspects of well-child anticipatory guidance parental education assessment of family psychosocial environment family-centered care helpfulness of care

MGH Language Concordance Project Provider Measures: competence: language skills populations Questionnaire based on two field-tested instruments that assess provider self-reported cultural experience working w/minority cultural competence training perceived effectiveness

Analysis - 1

  Bivariate: Control variables (parent education, marital status, yrs in US, child’s insurance status, site of care) & main outcome variables (PHDS domain scores); if p< = .10, forced into regression models T-tests: Differences in mean PHDS scores between language concordant/discordant dyads and users/non-users of interpreters

Analysis - 2

  Multivariate: site Step-wise forward and backwards multivariate linear regressions, controlling for variables significant in bivariate analysis, and Multi-level modeling: characteristics?

Multilevel random intercept models to understand provider characteristics’ effects on quality of care (patient = first level; provider = second level), i.e., how much of variation in QoC measures is due to patient characteristics and how much due to provider

MGH Language Concordance Project Findings: Language concordance not significantly associated with any of these PHDS quality of care measures when controlling for SES Provider self-perceived effectiveness was associated with higher quality scores for family-centered care and helpfulness of care ( how content is delivered) Use of interpreters was significantly associated with assessment of family environment ( what content is delivered)

Limitations

    Small sample size – 22 providers; influenced power of sub-set analysis (multi-level modeling) Relatively low response rate – 43% of parents (76% - provider) Study sites part of larger hospital system that has worked to address organizational cultural sensitivity; may dilute effects of provider language ability on QoC “Interpreter use” measure does not allow us to analyze which aspects of interpreter’s role affect QoC measures

MGH Language Concordance Project Implications of Findings: Cultural sensitivity, as measured by providers’ self-perceived effectiveness, can transcend language barriers and be acquired separate from language skills In a similar fashion, medical interpreters provide culturally appropriate access to care that also transcends language barriers between provider and patient – HOW?

“Cultural Brokering” “The need for cultural and linguistic competence in health care delivery systems is emerging as a fundamental approach in the goal to eliminate racial and ethnic disparities in health. The concept of cultural brokering is integral to such a system of care.” (National Center for Cultural Competence. Georgetown University Center for Child and Human Development Georgetown University Medical Center, 2004)

Who are cultural brokers in the health care system? *

Diverse group of individuals that ranges from immigrant children to organizational leaders: - outreach and lay worker - peer mentor - community member/pt - health educator - administrative leader - social worker - health care provider - program manager interpreter - board member - program support personnel

What is the role of a cultural broker?* As intermediary who bridges the cultural gap by communicating cultural differences and similarities between individuals As mediator and negotiator of complex processes between organizations, governments, communities, interest groups, or countries * National Center for Cultural Competence. Georgetown University Center for Child and Human Development Georgetown University Medical Center (2004)

What Does a Cultural Broker Do?

Liaison: Has knowledge of health care system and their cultural group/community – serves as bridge between the two Cultural guide: has the trust of both communities, so can facilitate organizational/institutional change, community development

What Does a Cultural Broker Do?

Mediator: can help establish trust between medical and lay communities and work to resolve conflicts Change agent: community promotes behavioral and environmental changes that lead to improved organizational capacity to effectively meet needs of the

Interpreter as Cultural Broker  Cultural brokering is an essential function of a medical interpreter  In medical settings, we not only broker between the majority and minority cultures, but also between the medical and layperson cultures

REMEMBER THIS?

The Making of a Medical Interpreter Part 4: Success?

. . . . . .

What changed?

Interpreter As Cultural Broker - 1 Came to understand that cultural brokering was an essential part of my role as an interpreter

Interpreter As Cultural Broker -2

Developed better cultural brokering skills: Better understanding of Deaf community, particularly regarding health care system Better understanding of my own cultural identity and biases Improved ability to advocate Improved skills in cross-cultural communication Better skills in educating/increasing awareness

“Interpreters are the most powerful people in a medical conversation.” ~ Head of Interpreting Services at a major private U.S. Hospital, May 1999 (B Davidson, The interpreter as institutional gatekeeper: The social-linguistic role interpreters in Spanish-English medical discourse. Journal of Sociolinguistics, 4 (3), 379-405)

FOR DISCUSSION:

Do you think cultural brokering is an essential function of medical interpreters? Why or why not?

Can you think of examples that illustrate how an interpreter functions in this way?

Do you think that acting as a cultural broker may violate your professional Code of Ethics?

ACKNOWLEDGMENTS and THANK YOU     Alexy Arauz-Boudreau, MD, MPH, Principal Investigator, Language Concordance Project, Center for Child and Adolescent Health Policy, Massachusetts General Hospital, Harvard Medical School Diana Mele, MA, LMHC, IC/TC, Associate Professor, Health Services Program, Deaf Studies, Interpreter Training Program, Division of Law, Education, and Social Professions, Northern Essex Community College Irma Kahle, MJEd, CI, CT, Director, The Mentorship Program, Massachusetts Maureen Lundergan, NIC, Northern Essex Community College

Select References - 1

    Davidson, D. The interpreter as institutional gatekeeper: The social-linguistic role interpreters in Spanish-English medical discourse. Journal of Sociolinguistics, August 2000; 4 (3), 379-405) Dysart-Gale, D. Communication Models, Professionalism, and the Work of Medical Interpreters, Health Communication, 2005; 17(1):91-103.

Elderkin-Thompson, V, Silver, RC, Waitzkin, H. When nurses double as interpreters: a study of Spanish speaking patients in a US primary care setting, Social Science Medicine, 2001; 52(9):1343-58.

Ferguson, W, Candib, L. Culture, Language, and the Doctor-Patient Relationship, Family Medicine 2002; 34(5):353-61.

Select References - 2

   Flores, G. The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research Review, 2005; 62(3):255-99.

Green, A, Ngo-Metzger, Q, Legedza, A, Massagli, M, Phillips, R, Iezzoni, L. Interpreter Services, Language Concordance, and Health Care Quality – Experiences of Asian Americans with Limited English Proficiency, Journal of General Internal Medicine, 2005; 20:1050-1056.

Haffner, L. Translation Is Not Enough - Interpreting in a Medical Setting, In Cross-cultural Medicine – A Decade Later [Special Issue]. Western Journal of Medicine, 1992; 157:255-259

Select References - 3

   Iezzoni L, O’Day B, Killeen M, Harker, H. Communicating about Health Care: Observations from Persons Who Are Deaf or Hard of Hearing. Annals of Internal Medicine. 2004;140:356-362 Jacobs, E, Lauderdale, D, Meltzer, D, Shorey, J, Levinson, W, Thisted, R. Impact of interpreter services on delivery of health care to limited-English-proficient patients. Journal of General Internal Medicine. 2001; 16(7):468 474.

Karliner, L, Jacobs, E, Chen, AH, Mutha, S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 2007; 42(2):727-54.

This translation remains but an idea of the thing, and not the thing itself.

- Samuel Beckett