million Americans rely on community health centers
community health center patients need care in a language other than English
of participants were interpreting without formal training
of participants self-reported as native Spanish speakers, but none tested to the native level
of participants who completed training achieved the qualifications necessary to interpret in the health center
When patients receive care in their own language, mediated by a professional interpreter, health outcomes significantly improve. Unfortunately, busy clinics often lack resources to meet the need for ongoing interpretation services essential for patient safety and care. In many cases, practices rely on heritage speakers without formal interpreter training to fill the language gap. A heritage speaker is an individual who grows up in a household or family environment where the primary language spoken is not the same as the dominant language spoken in their geographic location. Unlike native speakers who acquire a language from birth in a natural environment including formal schooling, heritage speakers typically acquire the language informally through family interactions or in community settings. This can lead to significant knowledge gaps – for example, the heritage speaker will likely not be familiar with specialized or medical vocabulary that would not be used in casual settings.
A team of doctors and researchers at WACO Family Medicine conducted the first comprehensive study of an easy, affordable process to train and test heritage-speaking employees as qualified medical interpreters. Published in the Annals of Family Medicine in late November, this study used ALTA’s Breaking Boundaries in Healthcare medical interpreter training course and Interpreter Skills Assessment to train and assess a cohort of bilingual staff at a community health center. The results are significantly positive, showing the efficacy of the course and outlining a simple process for leveraging the cultural and linguistic strengths of heritage speakers while elevating patient care and meeting legal requirements.
Given limited resources and the significant financial burden posed by providing sufficient remote interpretation to meet high demands, leveraging existing heritage speaker staff through this accessible training resource can go a long way to address what is fundamentally a matter of health equity – the provision of care that a patient can understand.
This is the first published, comprehensive study to determine if a standardized, easily replicable, and cost-effective training process could improve medical interpretation skills and formally qualify dual-role heritage speaker interpreters.
The study took place in a community health center, with 137 participants who are heritage Spanish speakers. These individuals self-reported their language proficiency, took an oral proficiency test in Spanish, underwent a pre-assessment for interpreter skills, completed ALTA’s 40-hour online medical interpreter course, followed by a post-training interpretation assessment. Results were analyzed using multivariate regression analysis, Spearman’s rank-order correlation, and paired t-tests.
The study concluded that an affordable, online interpreter training program like ALTA’s Breaking Barriers in Healthcare is an effective preparation for heritage speakers to become qualified interpreters.
Statistics cited below reference the research cited within the article.
8% of the US population is currently considered to have limited English proficiency. The population served by community health centers (nearly 10% of the US population), is made up of nearly ¼ individuals who are best served in a language other than English.
Current national regulations require health care entities that receive federal remuneration to take “reasonable steps to provide meaningful access” to patients with limited English proficiency. They stipulate that interpreters should be “qualified,” meeting three standards: (1) adhere to generally accepted interpreter ethics principles; (2) demonstrate proficiency in spoken English and the target language; and (3) be able to effectively and accurately relay oral messages from one language to another, and vice versa.
There is, however, no federally mandated standard for assessing interpreter language proficiency, and training is not explicitly required. Two national certification bodies have developed a formal certification pathway for professional interpreters. One of the required components is completion of a 40-hour interpreter training course focused on ethics and professional practices.
There are many barriers to providing interpreters in the ambulatory setting, with cost being a principal concern. In most states, the expense for interpretation services is borne by the health care organization and is not reimbursed by insurance or governmental programs. These financial issues are magnified in community health centers which have a greater proportion of uninsured and underinsured patients, and up to three times as many patients with limited English proficiency.
A common strategy to meet interpretation needs is the use of a dual-role interpreter (an assessed bilingual employee who interprets in addition to their primary job duties). However, many ambulatory settings, like community health centers, rely on an important asset in lieu of formally qualified dual-role interpreters – heritage speakers.
Heritage speakers are bilingual individuals who have a cultural connection with the heritage language but may not have formal education in that language. Many heritage speakers have been system navigators and cultural brokers between their families and the local medical system, so they have the advantage of familiarity with the community and clinic-specific knowledge. Because they are part of clinic staff, they understand the dynamics and intricacies of individual clinics, and can leverage relationships that help get things done. Moreover, providing this type of support works as a productive and satisfying channel for the desire to support their community.
Heritage speakers, however, may struggle with more specialized and formal language, resulting in difficulties when they encounter complex demands in a medical setting. For example, heritage speaker medical staff may overestimate their language proficiency and underestimate their medical language limitations. A heritage speaker’s unique bilingual skills do not equate to the ability to interpret in a medical setting, as medical interpretation is a learned skill. They can, however, readily build on existing knowledge to refine vocabulary, register, and accuracy. These factors make them well-suited for targeted training and valuable assets for interpretation in ambulatory care settings.
For a full discussion of the methodology, please see the publication (Medical Interpreting in Primary Care: Design and Validation of a Replicable Training Program | Annals of Family Medicine)
All employees who provided dual-role interpretation services in Spanish at a large community health center participated in a medical interpretation quality improvement project.
Participants completed an online demographic survey to determine their educational background, speaker classification, history of providing interpretation, and self-estimation of language and interpretation skills. After this, participants took an oral proficiency assessment, with results reported on the ACTFL scale.
Next, each participant completed a pre-intervention assessment – ALTA’s IVR Medical Interpreter Test. Results were reported on ALTA’s 12-point proprietary scale. Participants were not informed of their results.
All participants who completed initial testing were enrolled in ALTA’s 40-hour medical interpreter course, Breaking Boundaries in Healthcare. This is an asynchronous online course that covers the content required to begin working as a professional medical interpreter, while also providing remote live coaching, and optional Spanish-language interpretation practice modules.
Following successful completion of the training, participants completed a formal medical interpretation test through ALTA, comprised of a live, dual-rater assessment conducted by telephone. Results were reported on the same 12-point scale for comparison to the pre-intervention results from the IVR Interpretation test. Evaluators were unaware of the participants’ prior pre-intervention assessment results.
For a full discussion of the results, please see the publication (Medical Interpreting in Primary Care: Design and Validation of a Replicable Training Program | Annals of Family Medicine)
Of 137 enrolled participants, 87 completed the training and post-assessment.
The nationwide demand for qualified medical interpreters is high. In many ambulatory settings, the need for medical interpretation cannot be met by utilizing remote or in-person professional interpreters alone, due to limited resources. This study evaluated an innovative approach to address this need, leveraging the unique linguistic and cultural strengths of heritage speakers and validating a cost-effective, replicable training process to qualify medical interpreters.
The study confirmed prior research that bilingual individuals have limited ability to predict their language proficiency, and found that no other self-reported factors (for example, prior interpreting experience) predicted the individual’s general Spanish proficiency or medical interpreting ability. A key takeaway for health care administrators is that they cannot rely on staff’s self-reported language ability in an interpretation role. Medical language proficiency for interpreting must be formally assessed as required by federal regulations. Most importantly, heritage speakers are valuable assets for bridging the language gap between providers and patients, perfectly positioned for targeted training to step into medical interpreter roles in ambulatory care settings.
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