1. Translation or Interpretation? Training bilingual volunteers to work as Health Care Interpreters Emily Fletcher, UCSD MS4 and SSRFC Resource Development Manager. Ellen Beck, Executive Director/Advisor of the UCSD Student-Run Free Clinic Project Michelle Johnson and Sunny Smith, Co-Medical Directors of the UCSD Student-Run Free Clinic Project.

2. Agenda The need for trained interpreters What is involved in “training”? How to access a training program for the interpreters at your own clinic, free of charge

3. Definitions Translation vs. Interpretation – Both move from a “source” language to a “target” language – Translation involves written language, while interpretation involves spoken language Trained interpreter vs. ad hoc interpreter? – Ad hoc interpreters tend to be patient’s family members, or bilingual staff members at the clinic, whereas trained interpreters are unrelated, objective third parties trained in the skills of interpretation Summarizing vs. interpreting – Interpreting strives to render the message into the target language exactly as it was said, without adding, omitting, or substituting, while summarizing may leave things out

4. Why do we need interpreters? Language barriers in U.S. patient population Legal responsibility Health outcomes

5. Why do we need interpreters? Language barriers in U.S. patient population – 2000 Federal Census* – 47 million people in the U.S. speak a non-English language at home – predicted to expand to 69 million by 2010 Half of these have “limited English proficiency” (LEP) *http://www.census.gov/prod/2003pubs/c2kbr-29.pdfhttp://www.census.gov/prod/2003pubs/c2kbr-29.pdf

6. Why do we need interpreters? Legal responsibility: ◦ Title VI of the 1964 Civil Rights Act  “prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance.” ◦ Department of Health and Human Services Standards for Culturally and Linguistically Appropriate Services [CLAS]

7. Why do we need interpreters? Health Outcomes #1 ◦ Limited English Proficiency (LEP) has been associated with:  Fewer preventive visits (mammograms, Pap smears)  Higher resource utilization for diagnostic testing in Emergency Rooms  Lower rates of follow-up visits  Lower overall health status scores  Worse adherence to prescribed medication regimens

8. Why do we need interpreters? Health Outcomes #2 ◦ Limited English Proficiency patients in an Emergency Department who needed but didn’t get an interpreter had:  Worse understanding of diagnosis and treatment  More tests done, at higher overall cost  Delays in start of treatment, management and hospital discharge  Less satisfaction with their care

9. Why do we need trained interpreters? Health Outcomes related to interpreter training – Patients who use trained interpreters, in comparison to ad hoc interpreters, show*: Improved communication (fewer errors in interpretation, greater comprehension for patients and healthcare providers) Improved utilization of care Better clinical outcomes – More diabetics met ADA guidelines for care – Equivalent diabetic complication rates and Hemoglobin A1c levels compared to English-speaking patients – Lower rates of instrumental vaginal delivery and Cesarean section deliveries Improved patient satisfaction *Karliner et al 2007

10. What is involved in “training”? The history of healthcare interpreting in U.S. is somewhat disorganized – No federal certification program – Several groups formed over the years (IMIA, CMI, CCHI, CHIA, NCIHC, etc. etc.) – Currently, 2 certification programs National Board of Certification for Medical Interpreters (CMI) began certifying in October 2009 Certification Commission for Healthcare Interpreters (CCHI) began certifying in October 2010 – Both programs are similarly priced ($30 application, $150 for written test, $250 for oral test)

11. Becoming an Interpreter ◦ Step 1: Selection criteria  Bilingual (verify fluency)  Basic cultural knowledge  Maturity  We recommend a screening interview including a practice patient case for all volunteers ◦ Step 2: Training ◦ Step 3: Supervised Practicum  We highly encourage accompanying new interpreters on their first few times interpreting  Formalized, periodic assessment would be even better

12. SSRFC Interpreter Training Module Interpreting Basics Based on the Program Content Standards laid out in the NCIHC’s “Proposed National Standards for Healthcare Interpreter Training Programs” ◦ Interactive components  Background knowledge of role of interpreting in society  Ethics and Standards of Practice  Culture and its impact on health and communication  Interpreting Skills workshops ◦ Homework/Readings  Relevant terms in linguistics and communication  Health terms, concepts, and the biomedical model ◦ Assessment  Written competency test

13. Interpreting Skills First person interpreting (5 constituent tasks) ◦ Active listening ◦ Note-taking ◦ Memory retention ◦ Mental translation/transposing ◦ Speaking in target language Introduction/Pre-session with patient and provider Intervention ◦ Transparency Positioning

14. Demonstration of Skills Session: Positioning Next to the patient Patient Bed PatientProvider

15. Demonstration of Skills Session: Positioning Between patient and provider Patient Bed PatientProvider

16. Demonstration of Skills Session: Positioning Next to the provider Patient Bed PatientProvider

17. How to access free interpreter training http://www.studentrunfreeclinics.org/

19. Review What is the difference between translation and interpretation? – Written vs. spoken Difference between ad hoc vs. certified interpreter? – A certified interpreter has passed a formalized exam (such as those offered by CCHI or CMI). Ad hoc interpreters are often family members or bilingual staff members Why does the quality of interpretation matter in health care settings? – One reason: Better health outcomes for our patients! Most important factor in interpreter positioning? – Patient and provider can maintain eye contact. Where can you find a free interpreter training program (1 month from now)? – www.studentrunfreeclinics.org under “Resources” www.studentrunfreeclinics.org

20. References Bischoff, A., T.V. Perneger, P.A. Bovier, L.Loutan, and H.Stalder 2003b. “Improving Communication between Physicians and Patients Who Speak a Foreign Language.” British Journal of General Practice 53: 541-6 California Heathcare Interpreters Association Standards & Certification Committee. “California Standards for Healthcare Interpreters: Ethical Principles, Protocols and Guidance on Roles & Intervention.” 2002 available at www.chia.ws/standards.htm Hornberger, J.C, C.D. Gibson Jr., W. Wood, C. Dequeldre, I. Corso, B.Palla, and D.A.Bloch. 1996. “Eliminating Language Barriers for Non-English-Speaking Patients.” Medical Care 34: 845-56 Jacobs, E.A., D.S. Lauderdale, D. Meltzer, J.M. Shorey, W. Levinson, and R.A. Thisted. 2001. “Impact of Interpreter Services on Delivery of Health Care to Limited-English-Proficiency Patients.” Journal of General Internal Medicine 16:468-74. Karliner, LS et al. Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature. Health Services Research 42:2 (April 2007) Medical Interpreting and Cultural Competency Orientation presented by Office of Patient&Community Relations, Stanford Hospital and Clinics. 2004 National Council for Interpreting in Health Care “Guide to Interpreter Positioning” Ngo-Metzger, Q., M.P. Massagli, B.R. Clarridge, M. Manocchia, R.B. Davis, L.I. Lezzoni, and R.S. Phillips. 2003. “Linguistic and Cultral Barriers to Care: Perspectives of Chinese and Vietnamese Immigrants.” Journal of General Internal Medicine 18:44-52. http://www.census.gov/prod/2003pubs/c2kbr-29.pdf Special thanks to Shirin Alonzo, M.D., M.P.H.

21. Thank you!