Hablamos Juntos is pleased to announce its selection of ten grantees to serve as demonstration sites for its national project, “Improving Patient-Provider Communication for Latinos.” The grantees include a large integrated health system, two privately-owned health plans (one for-profit and one provider-owned), two publicly-owned health systems, two educational institutions (an Area Health Education Center and a school of public health), two community-based organizations (one grassroots that is patient-focused and another representing the interests of hospitals and physicians), and one partnership of four independent hospitals. For more information on our grantees, click here.

The National Advisory Committee (NAC) provides the National Program Office (NPO) with overall guidance on the initiative and monitoring of the ongoing projects. During the first year, the NAC and NPO reviewed 23 full proposals, participated in 15 site visits, and recommended 10 applicants to the RWJF Board of Trustees for the planning grants. The NAC is comprised of distinguished leaders across the country and include:

National Advisory Committee Meets Twice

The NAC convened for its first meeting in Arlington, VA on May 14 and 15 for discussion and to review twenty-three proposals submitted by invitation of the NPO. Three members of the Hablamos Juntos staff participated, while Jeanne LeBrecque, Vice President of Government Products for The M Plan, presided over the meeting as chair of the NAC. The meeting was a success. After hours of painstakingly reviewing, discussing, and praising each submitted proposal, the field was narrowed to fifteen sites that were recommended for site visits. The decisions were extremely difficult for the NAC members, as each invited proposal showed excellent potential and compassion for the limited English proficiency (LEP) population.

The NAC met again in San Diego, CA in August to review site visit results and to recommend ten applicants for planning grant awards. The Robert Wood Johnson Foundation recently announced the ten grantees in a press release on October 15, 2002.

Make sure to bookmark www.hablamosjuntos.org or www.wespeaktogether.org for easy access to the latest information on .

Hablamos Juntos launched a new and improved website in July, 2002. Many changes were made to make the site more useful to all who visit. In the new “Resource Center” you will find answers to basic questions about language access, useful tools for health care providers on a wide range of topics, the most recent research in the area of language access in health care, and much more.

Members of the media may wish to visit the new “Media Center” to watch for the latest press releases and to find resources and information on Latinos. These are just two new additions to our site.

On September 30, 2002, Former Presidents Gerald Ford and Jimmy Carter pledged their support to a national initiative to focus attention on the plight of the tens of millions of Americans who lack health insurance.

The former presidents will serve as honorary co-chairs of Cover the Uninsured Week, which is being organized by the Robert Wood Johnson Foundation and a diverse group of national organizations. The weeklong series of events will be held from March 10 to March 16, 2003, in communities from coast to coast. Data released by the U.S. Census Bureau make clear that the problem of the uninsured has grown worse over the past year. The report reveals that 41.2 million Americans were uninsured in 2001, up 1.4 million from the previous year.

Click here for more information.

Late last fall contracted with the National Council on Interpreting in Health Care (NCIHC) to fill a gap in language access literature. Two papers resulted from this contractual relationship, Models for the Provision of Language Access in Health Care Settingsand Models for the Provision of Health Care Interpreter Training. The papers provide an overview of the current understanding of models for developing interpreter services and the skills and training these individuals should have. They are useful in developing a common language, and provide a basis from which to develop building blocks to develop language services. Professionals working as interpreters in health settings have pushed the dialogue on quality in medical interpreting, and we are building on this dialogue.

The first paper that the National Council on Interpreting in Health Care (NCIHC) produced, Models for the Provision of Language Access in Health Care Settings, was written by Bruce Downing, Ph.D., and Cynthia E. Roat, MPH. This paper describes a variety of approaches to develop language capacity in healthcare organizations. The approaches are organized into broad models with subcategories. The paper is written from the viewpoint that clear, meaningful communication between patients and providers is of utmost importance. It also takes into account the notion that language and culture are inseparable, and that both providers and patients must be aware of the role of culture in their communication exchange. It outlines various models implemented across the United States and explains the strengths and limitations of each. These approaches include the development of: 1) bilingual providers – an approach to either increase the bilingual capabilities of both native Spanish speakers and native English speakers to provide direct services in Spanish or to increase the number of bilingual speakers entering the health professions; 2) bilingual patient model (the ESL approach), in which the patient gains command over the English language; 3) interpreter models including ad-hoc models and dedicated interpreter models; and 4) face-to-face, telephonic, and video interpreting. An outline of a variety of exemplary program models around the country is also included.

The second paper, Models for the Provision of Health Care Interpreter Training, examines the lack of and growing need for competent medical interpreters in the health care community. After reviewing various training programs offered in different states, NCIHC found that there is a great need for “standardized, comprehensive training curriculum for medical interpreters,” and suggests governmental regulations for training requirements for medical interpreters. The training programs available vary in quality, length, style, and end result. The NCIHC argues that the lack of a standardized interpreter-training curriculum has resulted in the proliferation of training approaches to medical interpreting and is “ultimately due to the absence of national standards within the medical interpreting profession itself.”

The paper outlines various medical interpreter-training programs along with their advantages and disadvantages in order to continue the discussion on what is needed to establish minimum criteria for a standardized medical interpreter-training program. The training programs examined include: 1) academic training programs; 2) bilingual healthcare employee training programs; 3) community training programs; 4) intensive training of at least 40 hours; and 5) agency training programs. The paper suggests criteria needs to be developed for the critical components of training that will lead to well-trained, competent interpreters of content and skill. NCIHC suggests that training programs can be evaluated based on the following criteria: 1) length of training; 2) trainer qualifications; 3) language screening; 4) content of training; 5) skill practice; 6) language-specific work; 7) practicum; and 8) post-test of basic competencies.

The Access Project, an initiative of the Center for Community Health Research and Action, recently released What a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency, a report that presents national findings from the “Community Access Monitoring Survey”. Based on responses of 4,161 uninsured respondents who received care at one of the 23 urban hospitals included in the study, it compares the perceptions and experiences of adults who needed and had ready access to an interpreter with both those of adults who needed and did not have an interpreter readily available and those who did not need an interpreter.

The findings show that uninsured respondents with limited English proficiency (LEP) who have access to an interpreter have strikingly better experiences in a wide range of areas, including ability to understand medication instructions, ability to get financial assistance to pay for care, and overall satisfaction with their health care encounter, compared to those who did not have an interpreter. One finding was that 27% of patients who needed (but did not have) a medical interpreter did not understand instructions for taking medications, compared to only 2% of patients who had a medical interpreter. The study also found higher patient satisfaction with courtesy and helpfulness of staff when a medical interpreter was available. Patients who used medical interpreters were more likely to perceive the facility as accepting and open, and were more likely to come back for future health services. Medical interpreters were found to be instrumental in providing financial information, such as how to pay for prescription drugs.

The study also showed that medical interpreters were beneficial to providers. Language barriers are problematic because providers may not be able to obtain information about concurrent treatments or medical history. Medical interpreters increased the likelihood that an accurate diagnosis is made. Because patients are more likely to use an outpatient clinic instead of the emergency room, health care institutions such as hospitals benefit when a medical interpreter is available.

Implications of the Access Project research include…

Click here to listen to a web-cast on the findings.

Action Kit Under Development by The Access Project

Working with the National Health Law Program (NHeLP), The Access Project is working to develop an action kit for healthcare organizations explaining reimbursement options available for language services under the Medicaid and State Children’s Health Insurance Program (SCHIP) programs. The kit will be used to educate providers, immigrant and health access advocates, and policymakers of existing reimbursement opportunities. To learn more about The Access Project, click here.

“Health communication must recognize social realities” concludes a report entitled, Speaking of Health: Assessing Health Communication Strategies for Diverse Populations published by the Committee on Communication for Behavior Change in the 21st Century, commissioned by the Institute of Medicine to examine how to improve the health of diverse populations. One way we deal with real world complexities is to classify people who share common characteristics into broad groups, but demographic groupings are ”limited and crude categories with relatively little explanatory power” the report suggests.

The committee recommended that communications strategies recognize that demographic groupings represent a constellation of individuals with shared and unique life experiences, social processes and cultural artifacts. The examination of these particulars as they impact individuals is important to understanding the context for health communication. The report suggests that a focus on ethno-racial groups confuses culture with ethnicity and risks stereotyping. The use of these markers to describe populations also encourages a view of culture as static and creates the impression that groups are more homogeneous than they actually are. Most broad categorizations simplify the complexities that may be important to the development of effective strategies or may lead to unintended outcomes.

The committee first debated the problems inherent in categorizing people by race, ethnicity, and culture, since there is no consensus on how these categories are defined. For example, there is no biological, genetic, or scientific evidence to group people by race. Human beings are 99.9% similar at the genetic level, and there is so much intra-group variation within any given race or ethnicity that the categorization is often ineffective. Any given race or ethnicity will have diversity in gender, age, religion, geographic setting, etc. The Center for Disease Control has concluded that emphasizing race and ethnicity in public health diverts attention from factors influencing health. Race and ethnicity should be looked at as crude measures that require more probing to discern intra-group and regional variability. With regard to culture, the committee concluded that social and environmental factors as well as lived experiences influence attitudes and behaviors and the enculturation process of individuals. Common group experiences, such as language, music, food, and child-rearing practices create patterns of similar attitudes and behaviors which give rise to what on the surface may appear as a common “culture” or homogeneity. But it is an ongoing and ever changing constellation of influences and lived experiences as well as situations that result in variations among individuals of the same race or ethnicity.

The committee also studied the use of mass communication (such as television and radio commercials, tailored print and telephone-delivered interventions) used in attempts to improve health behaviors. The committee concluded 1) it is unlikely that the same message content, medium, and format will be received and understood equally by everyone in the population, and 2) prevention and treatment interventions aimed at changing behavior need to be appropriate and acceptable for the population and take into consideration a community’s historical, social, and cultural context.

The same can be said about language services. Broad categories such as "Spanish speakers" serve to mask the complexities involved in addressing language barriers. It also promotes a misconception that there is a uniform and static use of Spanish among speakers or that their ability to speak Spanish is comparable. Spanish is the primary language in more than 20 countries with regional and cultural variations. Some related to differences arising from common cultural practices such as in the basic staple "beans" called frijoles by Mexicans who favor pinto beans and called habichuelas by Puerto Ricans who use red kidney beans. In Venezuela "beans" are called caraotas and porotos in Uruguay but in both countries frijoles is also used. Curandero(a) is commonly used by Mexicans to refer to folk healers while Puerto Ricans will refer to santiguadora. How important are these language use differences? Are there substitutes that can be used?

There are many variables embedded in the description of Spanish speaker. Some key variables for immigrant Spanish speakers are age of arrival, length of time in the US and exposure and use of English. The length of time in this country may affect both the Spanish speakers understanding and use of English as well as their maintenance and use of Spanish. Frequently, US born Latinos who learned Spanish as their first language retain very little Spanish speaking ability into adulthood, particularly if they have few opportunities or little need to speak Spanish. It is also not uncommon for an immigrant from Mexico, after extended periods in the US to return to their country of origin to find their native tongue "rusty" or to receive comments from friends and family about "Americanized" Spanish.

Language is the code by which we communicate. Every word and the way they are strung together help to convey messages from one person to the other. The words used and the meaning assigned to those words need to be understood by both the sender and the receiver. That is the challenge in communicating. The challenge is greater when communication is across culture and language. Travelers visiting other countries quickly learn the perils of trying to communicate in an unfamiliar language and how common word use can be distinctly different. Words do not always mean the same, not even in English. Take for example the word “boot.” Most American listeners would immediately think of a type of footwear but in British English, "boot" means the trunk of a car. More on point, the words "managed care" can be used as a noun to describe a form of reimbursement or a verb when the words are given independent meaning. Managed care, as a system of reimbursement has no counterpart in Spanish because this is uniquely American and the idea of "care being managed" is a stretch for many Latinos who firmly believe their human condition is the design or will of God.

In the United States word use differences occur from language adaptations which combine English and Spanish words. For example, parquiar derived from the English “to park” is used by many US based Spanish speakers replacing the Spanish word estacionar. The word watchar is used to mean “watch out” or “look out” rather than the word mirar.

Understanding the language use of the population to be served is a beginning step to developing effective language services. This is one of many issues the NPO will continue to explore on this website.

Click here to get a copy of the report Speaking of Health.

A national survey conducted by The Latino Coalition (TLC) lends support to Hablamos Juntos’ mission to decrease the language barrier between providers and patients via medical interpreters, translation, and signage in Spanish. TLC is a research institute in Washington, D.C. that closely monitors public policy at the federal, state and local levels to determine its impact on the Latino communities throughout the US.

The phone survey was administered to 1,000 Latino adults in August of 2001, in the respondents’ preferred language. A significant number of Latinos (55%) preferred to use Spanish during the survey. For language spoken during everyday affairs, 29% of respondents spoke Spanish all the time, and 19% spoke Spanish most of the time. About one-quarter spoke Spanish and English equally around the house, while 9% spoke English all the time and 18% spoke English most of the time. A random sample included diversity in age, gender, and other demographic variables. When asked “what do you consider to be the greatest barrier that keeps Latinos from succeeding in the United States”, 29% of respondents answered “language”, more often than any other barrier. The TLC survey showed language to be a greater barrier than either education or discrimination.

Interestingly, the perception of language being a barrier varied between those being surveyed in English (14%) and those being interviewed in Spanish (41%). This statistic also varied between Latinos who have lived in the US for over 10 years (37%) and those who have lived in the US less than 10 years (44%). This is a reflection of the great diversity in language needs within the Latino community. Recent 2000 Census data had shown a large growth in the limited English proficient (LEP) population. The LEP population in the US is 11%, up from 8% in 1990. From 1990 to 2000 the Hispanic population grew 58% to 35.3 million.

Over half of Latinos (56%) felt that the Latino community should become more a part of American society, even if it means losing some cultural identity. One third of Latinos felt that their community should keep its own culture even if it means staying separate from the rest of American society.

Hablamos Juntos has conducted a literature review that has repeatedly shown language to be a barrier to health care, leading to decreased access, delayed care, and poor health status and outcomes. For example, physicians in one survey reported that over half of their patients do not follow medical treatments as a result of cultural or linguistic barriers. Language barriers can limit a physician’s understanding of the patient’s symptoms and increase the risk of complications when the physician does not know about other treatments or medical history.

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To see more milestones click here.

Feel free to contact any staff with questions or suggestions.

• Yolanda Partida, DPH, Program Director
• Rebecca Romo, Program Assistant