1. Overcoming Linguistic Barriers in Health Care
Challenges, Current Practices, and Directions for the Future

2. Number of Patients Needing Interpreter Services
2000 census: >46 million people in the US reported English was not their primary language
Nearly ½ of these (21 million) reported speaking English less than “very well”
US Census Bureau

3. Effects of Limited English Proficiency (LEP) on Health Care:
LEP patients…
Access preventative and primary care services less frequently
Are more likely to be non-adherent
Are more likely to be dissatisfied with their care
Are more likely to use the ED for primary care
Are more likely to be confused about their medications
Wilson 2005; Galbraith 2008

4. Interpreter Services and Legal Issues
Title VI of The Civil Rights Act (1964)
Requires all federally funded health care facilities to provide access to interpreters
Informed Consent
Requires ensuring patient understands diagnosis, treatment options, risks and benefits of treatments, risks of not treating
Sometimes done without trained interpreter
Often patient asked to sign English consent form
US Dept of Justice; Zabar 2006; Hunt 2007

5. Common Reasons Given for Not Using Interpreter Services
“It costs too much money”
“It takes too much time”
Jacobs 2007; Fagan 2003

6. The Costs of Interpreter Services
Cost varies between institutions
Some studies have reported costs:
Cost of outpatient interpreter services averaged $279 per LEP patient per year
Cost of inpatient interpreter services accounted for 1.5% of total cost of patient care
Jacobs 2004; Jacobs 2007

7. Potential Savings by Using Interpreter Services
Fewer tests ordered
Increased use of preventative services and primary care
Catching disease earlier may reduce cost of treating it (ex: Colon Cancer)
Keeping chronic conditions well-managed may avoid costly complications (ex: amputations in DM)
Cheaper to treat simple complaints in an office than in the ED
Jacobs 2004; Jacobs 2007

8. Effect of Interpreter Services on Time it Takes to See Patients
There is evidence to suggest that use of telephone interpreters or patient-supplied interpreters (family and friends) does increased length of clinic visit, but that use of professional interpreters does not
This may be due to increased efficiency of professional interpreters
Fagan 2003

9. Current Interpretation Methods: Telephone Interpreters
Mixed data on how patients feel about this method
Evidence does not suggest that patients are dissatisfied with telephone interpreters, but some may prefer using family and friends
The ability to access interpreters for nearly 200 languages 24hrs a day
Telephone interpreters will likely continue to play a role in patient care
Kuo 1999; Lee 2002; Language Line Services

10. Current Interpretation Methods: Ad Hoc Interpreters
Includes bilingual hospital or clinic staff, and patient’s family or friends
Lack training in interpretation
May have limited knowledge of medical vocabulary
May have insufficient fluency
Use of Ad Hoc interpreters increases interpretation errors
Hunt 2007; Flores 2005

11. Use of Bilingual Staff as Interpreters
Neither providers not patients very satisfied with this method
Takes staff member away from other duties, or adds to workload
Should have access to at least some interpreter training, and should be compensated for performing this service
May be the only option at times
Zabar 2006; Kuo 1999

12. Use of Patient’s Family/Friends as Interpreters
Patients are generally very satisfied with this method, while providers are not
Patients value:
Familiarity with the interpreter
Interpreter of the same gender
Availability to help with transportation and scheduling
Highlights need for interpretation services at every point in the process of health care delivery
Kuo 1999

13. Current Interpretation Methods: Professional Medical Interpreters
Should be used whenever possible
Most are highly trained, but there is no uniform certification process as of yet
National Board of Certification for Medical Interpreters
plans to have nationwide standardized certification program in place by late 2009
Written and oral examinations, recertification every 5 years
Jacos 2007; Natl Board of Cert for Med Interp

14. Language Concordant Physicians
Eliminates need for 3rd person in physician-patient discussions
Associated with better health outcomes
However, LEP patients still more likely to report decreased comprehension than their English-speaking counterparts
Not just language barriers – ?may also need to improve health care literacy
Too few language concordant physicians to rely on them alone
Doing so might limit pool of physicians LEP patients can see, perhaps reducing access to care
Jacobs 2007; Wilson 2005

15. What Can Be Done Now?
Providers need more training in using the various methods of interpretation effectively
Documents (information brochures, informed consent forms) should be translated into Spanish
Additional time scheduled for visits where an interpreter is needed
Multilingual phone systems
And of course...more research into this issue
Zabar 2006; Hunt 2007; Galbraith 2008

16. References
US Census Bureau. DP-2. Profile of selected social characteristics: Available at:
Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of Limited English Proficiency and Physician Language on Health Care Comprehension. J Gen Intern Med. 2005;20:  
Galbraith AA, Semura JI, McAninch-Dake, RJ, Anderson N, Christakis DA. Language Disparities and Timely Care for Children in Managed Care Medicaid. Am J Manag Care. 2008;14(7):
Jacobs EA, Shepard DS, Suaya JA, Stone EL. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. Am J Public Health. 2004;94:
Lee LL, Batal HA, Maselli JH, Kutner JS. Effect of Spanish Interpretation Method on Patient Satisfaction in an Urban Walk-in Clinic. J Gen Intern Med. 2002;17:
Schyve P. Language Differences as a Barrier to Quality and Safety in Health Care: The Joint Commission Perspective. J Gen Intern Med. 2007;22(Suppl 2):360-1.
US Department of Justice. Civil Rights Division. Title VI of the Civil RIghts Act of Available at:
Zabar S, Hanley K, Kachur E, Stevens D, et al. "Oh! She Doesn't Speak English!" Assessing Resident Competence in Managing Linguistic and Cultural Barriers. J Gen Intern Med. 2006;21:  
Hunt LM, de Voogd KB. Are Good Intentions Enough?: Informed Consent Without Trained Interpreters. J Gen Intern Med. 2007;22:
Jacobs EA, Sadowski LS, Rathouz PJ. The Impact of an Enhanced Interpreter Service Intervention on Hospital Costs and Patient Satisfaction. J Gen Intern Med. 2007;22(Suppl 2):
Kuo D, Fagan MJ. Satisfaction with Methods of Spanish Interpretation in an Ambulatory Care Clinic. J Gen Intern Med. 1999;14:
Language Line Services. List of Languages. Available at:
Flores G. The Impact of Medical Interpreter Services on the Quality of Health Care: A Systemic Review. Med Care Res Rev. 2005;62(3):
The National Board of Certification for Medical Interpreters.