Description of the condition
Population mobility is a global phenomenon, with about 214 million people, 3.1% of the world's population, living outside their country of birth (UN 2008). This number is increasing by almost 2% each year (UN 2008), creating various challenges for the countries of origin, host countries, and the migrants themselves (IOM 2010). Among these challenges is migrants' health. When they move, migrants can become vulnerable to disease and may face barriers to accessing appropriate health care due to poverty, marginal status, and/or limited access to social benefits (WHO 2003; IOM 2005; Ghent 2008). Although several studies have observed that the health of some populations improves after migration (Friis 1998), and that some populations are healthier than others, these positive effects may be lost over time (Ahmad 2004).
Because many migrants are not familiar with the local language, in face-to-face clinical settings they face language barriers that can diminish the quality of health care they receive. A number of studies have described the negative impact of language barriers on the quality of health services, on the utilisation of these services, and on patients’ health status as an outcome of service quality. These include excess hospitalisation, medical errors, and drug complications (Hampers 1999; Gandhi 2000; Bard 2004); poor access to medical care (Weinick 2000; Pippins 2007; DuBard 2008; Cruz-Flores 2011), and poor access to services promoting healthy behaviour change (Woloshin 1997; Jacobs 2005; Johnson-Kozlow 2009; Kaur 2009). Language barriers cause communication problems and misunderstanding of patients' explanations of their symptoms and health history. They also inhibit the health provider’s presentation of diagnosis, treatment and suggestions for healthful behavioural changes, and the development of a therapeutic patient-provider alliance. In the diagnosis and treatment process, and particularly for illnesses that cannot be identified by observable symptoms, this communication gap can lead to serious problems. The alleviation of language barriers may address these problems. One means of achieving this is by using trained medical interpreters.
Description of the intervention
A ‘trained medical interpreter’ works to overcome language and cultural barriers in a clinical setting (Hornberger 1997; Flores 2005; Bauer 2010; Leanza 2010) through oral restatement of words from one language into another language, simultaneously or consecutively. Trained medical interpretation is not simply any intervention involving an interpreter to provide a linguistic bridge between patient and health provider. There is no universal definition of the term 'trained medical interpreter', and different standards and training have been required by different institutions, agencies, and in various locations The International Medical Interpreters Association (IMIA) has defined standards of practice in the following three areas (IMIA 2007):
cultural interface (understanding, attitudes and practices to reduce culturally-based dissimilarities of perception, presentation, course, and outcomes of illness, wellness and treatment as between providers and patients), and
Reflecting these standards, we define a trained medical interpreter as an internal (staff member employed in health facility in which a patient receives services) or external interpreter (staff member employed in different organisation from health facility in which a patient receives services), who has received training in clinical interpretation, particularly in some or all of these three areas of practice. It is reasonable to assume that trained medical interpreters provide superior and more accurate interpretation than untrained interpreters.
There is variation in how trained medical interpretation is delivered and utilised. For example, the quality of interpretation may vary depending on the professional interpreter's training. In addition, the cost of using professional interpreters is often regarded as a barrier to use, even though some studies have reported that the use of trained medical interpreters can offer cost benefits to the healthcare system, over other approaches or no interpretation (Hampers 2002; Jacobs 2004). Two obstacles to such positive utilisation, as pointed out in a recent study, are the availability of trained medical interpreters and accessibility to the agencies that provide them (Hadziabdic 2011).
Our review will compare the involvement of trained medical interpreters with other approaches which have similar goals but do not involve trained medical interpreters. These include ad hoc interpreters, bilingual health providers, and translated materials (Riddick 1998; Flores 2005). An ad hoc external interpreter is a friend, family member, relative, etc. who takes on the role of clinical interpreter, but has not received any training in interpretation. Ad hoc interpretation may be more convenient but also problematic, because an ad hoc interpreter may lack appropriate interpretation skills and knowledge of medical terminology. Also, the patient’s confidentiality may be compromised, and vital information may be distorted (Launer 1978; Flores 2005; Leanza 2010). A bilingual employee (ad hoc internal interpreter) is a health worker or support worker in a healthcare facility who takes on the role of clinical interpreter without having formal training in interpretation (Johnson 1998; Elderkin-Thompson 2001; Sevilla Matir 2004; Bischoff 2010). Finally, translated materials include documents and flip charts that offer written communication without an interpreter. Health providers and patients can communicate by pointing to an appropriate phrase in their respective languages, but optimal use requires the health provider to be trained to use them effectively as well as the patient to be literate in his/her mother tongue, which is not always the case. Each of the above modes of intervention may be best suited to different circumstances (Garcia-Castillo 2007; Vazquez Navarrete 2009; Manias 2010).
How the intervention might work
One aspect of the quality of health care for migrant patients is the degree to which their specific linguistic, cultural, and any other needs stemming from their migrant status are met in the process of healthcare delivery. Effectively meeting these needs increases the likelihood of achieving desired health outcomes consistent with the current state of professional knowledge (Lohr 1990). Trained medical interpretation can impact on various aspects of healthcare quality. Specifically, it can improve communication quality (Baker 1996; Flores 2003), and patient and healthcare provider satisfaction with communication (Lee 2002; Al-Khathami 2010). The quality of communication can have a substantial influence on: the suitability of clinical responses; diagnostic certainty and the likelihood of testing (Dodd 1984; Drennan 1996; Hampers 2002); timeliness in seeking medical care (Drennan 1996); visit duration (Kravitz 2000; Hampers 2002; Fagan 2003); the utilisation of services including preventive screening (Bell 1999; Jacobs 2001; Bernstein 2002; Dang 2010); appointment keeping (Manson 1988; Sarver 2000); and the length of stay in hospital (Hampers 2002).
The context in which interpretation takes place can shape its effect, because medical interpretation is practised in different service settings and among different target groups. Our review will consider (in subgroup analyses) the following contextual factors, although we recognise that they may be poorly reported in studies:
Interpreters' training experience: Fulfilment or non-fulfilment of the three categories of standard practice recommended by IMIA, mentioned above, can influence the interpreter's competency. Interpreters' training experience can vary in terms of the content, duration and intensity of each of the three categories of standard practice (IMIA 2007).
Gender: The gender of the interpreter, or gender disharmony between the interpreter and patient, may influence their interaction (Roussos 2010).
Age of patient: Communication can differ between children, adolescents and adults due to differences in emotional development and cognitive ability. Quality of interpretation may influence the emotion and attitude of younger patients to health providers. For example, because paediatric patients may be intimidated in front of adults, they may not be able to verbalise their health condition (Purvis 2009).
Patient literacy: Information through interpretation for illiterate patients may be limited, since written materials in the patient's own language, for medication and for home follow-up or self-care, cannot be used as a supportive tool for medical interpretation.
Medical conditions that require sexual/cultural sensitivity: Some conditions such as reproductive illness, which are highly personal, call for sensitivity to sexual issues, which can influence the interaction between interpreter and patient.
Why it is important to do this review
Although some benefits of language interpretation are quite obvious, there is no systematic review of the effects of interpretation on the quality of health services. It is necessary to quantify the impact of interpretation on the quality of health care, in order to clarify its cost-effectiveness and the advantages it offers, as well as any disadvantages.
This review will provide such quantitative information on the impact of trained medical interpreters in face-to-face clinical settings, compared with other interpretation and translation measures. It will also present a subgroup analysis of the contexts in which interpretation takes place.
This information will offer essential assistance to policy makers, health facilities, and patients in the effective and efficient development of interpretation services, particularly in systems with a diversified context that serve patients with low proficiency in the local language.