Global migration continues to increase, and with it comes increasing linguistic diversity. This presents obvious challenges for both healthcare provider and patient, and the chapters in this volume represent a range of international perspectives on language barriers in health care. A variety of factors influence the best ways of approaching and overcoming these language barriers, including cultural, geographical, political and practical considerations, and as a result a range of approaches and solutions are suggested and discussed. The authors in this volume discuss a wide range of countries and languages, and cover issues that will be familiar to all healthcare practitioners, including the role of informal interpreters, interpreting in a clinical setting, bilingual healthcare practitioners and working with languages with comparatively small numbers of speakers.
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About the Author
Elizabeth A. Jacobs is Professor of Medicine and Population Health Sciences and Associate Vice Chair for Health Services Research at the University of Madison-Wisconsin, USA. Lisa Diamond is Assistant Member/Assistant Attending at Memorial Sloan Kettering Cancer Center, Immigrant Health and Cancer Disparities Service, New York, USA.
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Providing Health Care in the Context of Language Barriers
By Elizabeth A. Jacobs, Lisa C. Diamond
Multilingual MattersCopyright © 2017 Elizabeth A. Jacobs, Lisa C. Diamond
All rights reserved.
The Drivers of Demand for Language Services in Health Care
Societies with a rich diversity of skills and experiences are better placed to stimulate growth through their human resources, and migration is one of the ways in which the exchange of talent, services, and skills can be fostered. Yet migration remains highly politicized and often negatively perceived, despite the obvious need for diversification in today's rapidly evolving societies and economies.
(Appave & Laczko, 2011: 15)
Figure 1.1 illustrates the current complexity of global migration. Geographically, individuals tend to migrate first within their country, usually from rural to urban areas. Reasons for domestic migration may include changes in local conditions that force migration owing to economic (job seeking or employment changes), political (conflict or war), educational (degree or training seeking) or ecological reasons. If international migration occurs, this may happen first within the local region (e.g. South Asia) and then internationally. The most common pattern is from a low or middle income country to a high income country. Additionally, an individual's education level will often dictate how migration occurs, whether it is voluntary and driven by a confirmed opportunity, voluntary and driven by potential opportunity, or involuntary driven by a variety of reasons.
More than ever before, individuals migrate to other countries primarily for work opportunities when career advancement opportunities arise, their local economies do not produce enough opportunities for paid employment or when underemployment prevails. War and conflict zones may also drive workers from their country temporarily or permanently and transferring the skills of these migrants can prove challenging (The International Bank for Reconstruction and Development 2011; Appave & Laczko, 2011; Docquier et al., 2009). Nonetheless, migration for work often benefits many workers as they develop new technical, social and linguistic skills that may make them more competitive in their originating country labor markets and act as buffers against economic shocks (Durand & Massey, 2010; Siqueira et al., 2013; Walani, 2013; Shihadeh & Barranco, 2010; Bartram, 2010; Hagan et al., 2011; Tilly, 2011; Docquier et al., 2009). Migrating workers are also major contributors to the global economy through remittances: earnings sent back to the home country to the migrant's family often to pay for housing and healthcare costs (Carling, 2009). In 2014, the World Bank estimated that remittances sent home by migrating workers contributed US$400 billion to the global economy and would increase by 7–9% annually through 2020 (The World Bank, 2016). With international travel easier than at any other point in history, the 21st-century worker has a high probability of migrating permanently or temporarily for work at some point in their lifetime.
Yet as a global phenomenon, 21st century global migration patterns are changing health services delivery in countries around the world. For some healthcare systems, this presents new demands on service delivery while others see increased challenges on already stretched ones. Changing countries is stressful in good and bad ways and often impacts individual and family health. Legacies of origin country health system strengths and deficiencies will travel with the migrant in terms of their health profile. Whether they are an investment banker who has moved from New York to London or an internationally educated nurse from the Philippines who moves to the Middle East to staff healthcare systems or a Central American migrant fleeing stagnant economies and drug violence, newly arrived migrant workers undergo a transition period, often known as culture shock. The stress of the transition often affects their mental health as some individuals adapt more readily than others to new cultures, contexts and stressors while others may develop depression, anxiety and other mental health sequelae that affect their physical health, all as a direct result of their migration experiences and sudden absence of traditional support systems (Rudmin, 2010; Bauer et al., 2010; Riggs et al., 2012; Viruell-Fuentes et al., 2012; Teruya & Bazargan-Hejazi, 2013; Lassetter & Callister, 2008). Even though the cumulative causation of migration may increase social networks and support systems abroad (Fussell, 2010; Sanderson & Kentor, 2008) that may lessen the effects of migration experiences on health, the phenomenon's effects on health are complex.
Consequently, migrants may or may not access the healthcare system in their destination country when needed. Several factors influence these behaviors. First, insurance schemes play a large role in whether or not the migrant accesses the local healthcare system simply owing to whether or not they can get coverage in their new country. Even countries with universal health coverage do not necessarily provide coverage to new immigrants (Biswas et al., 2011; Docquier et al., 2009; Reyes & Hardy, 2015; Siddiqi et al., 2013). The second major factor is a language barrier. Even if a migrant comes from a country, for example, where English is an or the official language and has migrated to another English-speaking country, the language of healthcare systems and illness descriptors can be different enough to affect how and when the migrant accesses the healthcare system (Squires et al., 2013). When the migrant has little to no language skill in the official language(s) of a country, it becomes a major barrier to accessing and utilizing healthcare services. Even countries with long histories of receiving immigrants can be unprepared for the reality of individuals who cannot communicate effectively with a healthcare provider.
Migrant Identity and Health
Regardless of the reason for migration, researchers categorize migrants as documented, undocumented and refugee. The latter two situations have the greatest likelihood of affecting the health of individuals and their families because of the nature of the migration experience. Documented individuals who migrate generally have no greater risk for health issues when living and working in high-income countries than in their home country. Health risks associated with living and working in a low- or middle-income country are related to the disease burden inherent to the country and the ability of the local health system to respond to their needs or transfer the individual to another country for treatment.
Undocumented individuals migrate to a country without legal citizenship or work papers. Many may arrive in the country via a tourist visa and remain after it expires. Others arrive through human traffickers and may have been subject to emotional, physical or sexual abuse during the process. Nonetheless, once they arrive they contribute economically to countries by providing inexpensive labor, primarily in the service, agricultural and construction sectors. Health issues in this population can result from the migration experience, the success or failure of their integration into the new community or occupationally related injuries which may or may not receive timely treatment.
Refugees have fled their home country for political reasons. The United Nations (UN) defines them as:
Any person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside of the country of his former habitual residence as a result of such events, is unable or, owing to such fear, unwilling to return [to it]. (Source: UN Convention Related to the Status of Refugees and the 1967 Protocol)
The skills of these individuals and their education levels vary widely. Translating their skills into equivalent positions in the receiving country is often a challenge. Proof of education documents may be lost or unobtainable and training curricula may be sufficiently different that they do not meet the competency or credentialing standards of the receiving country. This means this population is at risk for underemployment or may need to repeat their education. These individuals are also at high risk for post-traumatic stress disorder and may manifest these symptoms physically. Asylum seekers may face similar challenges.
Language often cannot be separated from migrant status, which also impacts health, so healthcare organizations must also be knowledgeable about the particular health risks that result from the migration experience. In consideration of the aforementioned factors, this chapter focuses on how migration dynamics influence demand for language services in healthcare systems and the subsequent implications for policy (both organizational and national) and research. It will examine how these experiences start to create demand for language services in healthcare systems and conclude with recommendations to better account for the demands that language services place on healthcare organizations and systems.
Language Services: Definition, Outcomes Impact and Implementation Factors
Regardless of how the individual migrates, their ability to access the system through insurance schemes and bridging language barriers is what creates the demand for language services in health systems. It is widely reported in anecdotal evidence sources that when it becomes known in an immigrant community that a provider speaks their language, more patients seek care through that person. Organizations that provide good-quality language services also attract more clients. Increasingly, research shows that facilities with good-quality language services reduce 30 day readmissions and other costly complications of hospitalization (Lindholm et al., 2012; Betancourt et al., 2012; Tuot et al., 2012).
Language services, for the purposes of this chapter, are defined as the services or personnel an organization provides to bridge a client's language barrier. These services are essential for optimizing patient outcomes (Hacker et al., 2012; Jacobs et al., 2007, 2011a; Kosmider et al., 2010; Karliner et al., 2007; Eamranond et al., 2009; Fernandez et al., 2011; Ipsiroglu et al., 2005; Levas, 2011), even when controlling for potential confounders, and reducing differences in patient satisfaction with care (Jacobs et al., 2001, 2007, 2011b; Green et al., 2005; Grover et al., 2012; Ngo-Metzger et al., 2007; Karliner et al., 2007; Bagchi et al., 2011; Kanter et al., 2009; Ayanian et al., 2005). Language services can include language-concordant personnel who are not certified to conduct medical interpretation, language-concordant personnel who are certified to conduct medical interpretation, volunteer interpreters, paid interpreters, telephone interpreters and increasingly language interpretation technology available on smartphones and computers. It is well known that family members often provide interpretation for their relatives despite strong recommendations that they do not (Regenstein et al., 2008; Betancourt et al., 2012), but they are contributors to demand for language services because providers need to include them, as appropriate, in care planning. Interpreter use with limited English Proficient (LEP) patients, therefore, is essential for delivering patient-centered care (Green et al., 2005; Jacobs, 2000; Karliner et al., 2011; Nápoles et al., 2009; Radwin et al., 2013; Ngo-Metzger et al., 2009; Charlton et al., 2008).
Therefore, how these services are deployed in the healthcare delivery setting drives service demand and influences outcomes. Hsieh (2006) categorizes interpreters in the following ways: chance interpreter, untrained interpreter, bilingual healthcare provider, on-site interpreter and telephone interpreter. Chance and untrained interpreters have no formal training in interpretation, a bilingual healthcare provider may or may not, and the latter two have training.
Trained human interpreters are the most common ways that providers bridge a language barrier with a patient. Trained human interpreters view themselves as an integral part of the healthcare encounter, serving as communication brokers (Hsieh & Kramer, 2012; Hsieh, 2008), patient advocates for social justice (Hilfinger Messias et al., 2009; McDowell et al., 2011) and system brokers (El Ansari et al., 2009; Brisset et al., 2013). Policies that mandate or provide decision tools for interpreter service use have mixed results regarding their efficacy (Ginde et al., 2010).
Yet when demand for an interpreter arises, providers typically conduct a situational analysis that helps them determine when to use an interpreter, with situational acuity dictating interpreter need and not patient preference (Bischoff & Hudelson, 2010b; Rosenberg et al., 2007; Andres et al., 2013). When convenient for staff, telephone or computer-based interpreters are effective for bridging communication barriers with LEP patients (Tuot et al., 2012). Team-based strategies for interpretation are effective when there is a high volume of LEP patients (Schapira et al., 2008). It is more common, however, that providers use the most easily available interpreter, including other staff members and family, even when policies advise against this practice (Hsieh, 2006).
Generally, however, a lack of interpreter services causes most healthcare workers to alter their work patterns, thereby decreasing efficiency, increasing stress and increasing the threats to patient safety (Johnson et al., 1999; Cioffi, 2003; Jones, 2008; Elderkin-Thompson et al., 2001; Bernard et al., 2006). Interruptions to professional role execution increase threats to patient safety and underdiagnosis (Hadziabdic et al., 2011; Leng et al., 2010; Gany et al., 2007). Changes can result in increased provider stress owing to work reorganization (Bernard et al., 2005, 2006; Gany et al., 2007; Hadziabdic et al., 2011; Leng et al., 2010). Despite these risks, providers of all kinds tend to underutilize interpreter services and, therefore, affect both perceived and actual demand for language services (Gill et al., 2011; Bischoff & Hudelson, 2010a; Diamond et al., 2009, 2012).
Implementing language services
Language services are a critical component for meeting the goals of the Quadruple Aim – an international project to improve the quality, costs, and experiences of individuals accessing the health care system. The Quadruple Aim first emerged from the Institute for Healthcare Improvement as the Triple Aim and seeks to 'apply integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita' (Whittington et al., 2015). The newest fourth part of the aim focuses on improving the health worker experience. It was added to the goals of the project because poor health worker job satisfaction and retention has consistently been found to adversely affect the patient experience and system costs.
The Quadruple Aim has evolved into a global movement with more than 50 countries now actively applying these goals to their healthcare systems. A main focal point of the effort centers on improving the experience of care. For patients with a language barrier and their providers, that means systematically addressing how language services are implemented so that communication improves between all parties.
Excerpted from Providing Health Care in the Context of Language Barriers by Elizabeth A. Jacobs, Lisa C. Diamond. Copyright © 2017 Elizabeth A. Jacobs, Lisa C. Diamond. Excerpted by permission of Multilingual Matters.
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Table of Contents
Introduction 1. Allison Squires: Drivers of Demand for Language Services in Healthcare 2. Leah Karliner: Three Critical Steps to Enhance Delivery of Language Services in Healthcare 3. Elaine Hsieh: The Model of Bilingual Health Communication: A Theory Based Approach to Interpreter-Mediated Medical Encounters 4. Yvan Leanza. Camille Brisset, Rhéa Rocque and Alexandra Boilard: Challenges and Recommendations for Work with a Community Interpreter in Mental Health 5. Barbara Schouten: Toward a Theoretical Framework of Informal Interpreting in Healthcare: Explaining the Effects of Role Conflict on Control, Power and Trust in Interpreter-mediated Encounters 6. Rebecca Schwei, Mary Rhodes and Elizabeth A. Jacobs: Understanding the Advantages and Disadvantages of the Diversity of Approaches to Overcoming Language Barriers in Medical Encounters 7. Dana Canfield and Lisa Diamond: Language Concordance between Limited English Proficient Patients and Their Clinicians 8. Gwerfyl Roberts: Breaking the Silence: Identifying the Needs of Bilingual Speakers in Healthcare 9. Francesca Gany, C. Javier González, E. Zoe Schutzman and Debra J. Pelto: Engaging the Community to Develop Solutions for Languages of Lesser Diffusion 10. Fiona Irvine, Martin Partridge and Echo Yeung: Chinese Voices: Improving Access to Health Care 11. Ben Gray, Jo Hilder, Lindsay Macdonald, Rachel Tester, Anthony Dowell and Maria Stubbe: A New Zealand Perspective on Providing Healthcare for Patients with Limited English Proficiency 12. Lidia Horvat: Towards a New Approach for Culturally and Linguistically Responsive Healthcare: A Case Study of Developments in Victoria, Australia