Often the blame for sub-par written materials for LEP patients is placed on poor translations; however, in a recent Hablamos Juntos study, it was discovered that the root of the problem might in fact be the root of the translation.

In a review of multiple consent forms provided by the Philadelphia based grantee Hablamos Juntos en Temple, it was found that poor translations were many times the result of poor source documents written in English.

“We knew we weren’t doing everything perfectly, so we were happy to submit a cross section of various written materials for independent evaluation,” said Charles Soltoff, Hablamos Juntos Principal Investigator at Temple. “One of the major benefits of our participation was that it really opened our eyes. We realized that we needed to produce better English forms before we started translating.”

With this new insight, Hablamos Juntos began the Forms Project, an initiative to develop templates that provide a systematic approach to creating health care forms that are standardized across departments and understandable to patients. These templates will not only produce better English materials, but also eventually better forms for LEP patients.

The scope of the study was limited to consent forms because they are considered “essential documents” that must be made available in non-English languages according to federal guidelines. The consent documents that were reviewed varied widely in content and length, and also, consent forms for the same procedure were sometimes different across multiple Temple health care facilities.

Knowing that English originals are the basis for translated forms, Hablamos Juntos began with a review of the clarity of the English text, as well as the format and style of forms found among the Temple samples. In general, the text style in the English forms was too formal and specialized for the average reader to fully understand its meaning. For example, the phrase “administration of blood” could be easily substituted with a more understandable phrase such as “given blood.”

In addition, Hablamos Juntos found inconsistencies in the amount and quality of information provided on forms across departments. This problem was attributed to the lack of a single source for the production of forms, leading to a varying degree of information about procedures depending on the department. For example, the Consent to Transfusions and/or Blood Products consisted of five very short paragraphs whereas the Vaginal Delivery Consent consisted of 12 very long paragraphs. In addition, font style and size, layout, numbers/bullets and paragraphs were, in general, not consistent.

Not surprisingly, the translated Spanish versions retained the problems inherent in the English originals and were also saddled with additional issues related to poor translation and writing. Incorrect grammar, awkward sentence structure, misspellings, and false cognates were frequent problems. For example, false cognates such as ‘sometidas’ which means ‘put under’ was used for ‘submitted’ where in fact the correct word needed was ‘enviadas’. In another document, ‘trabajo’ was used for ‘labor’; ‘trabajo’ is a common Spanish word, but in Spanish ‘labor and delivery’, are encompassed in a single word: ‘parto.’  

These errors compounded with the already difficult and technical nature of medical forms are some of the primary causes for communication disparities around informed consent in health care facilities.

Before translation is attempted, the quality of English consent forms must be improved. Hablamos Juntos established criteria and researched web sites in order to find English consent forms that could serve as models. From a review of consent forms available through public web sites, it was determined that the most effective forms should include:

Only one web site contained template consent forms that fulfilled most of the criteria listed. Queensland Health, the Australian run health care system, developed a consent form template with simple formatting and standard sections including the following:

1. Interpreter Needed
2. Conditions and Procedure
3. Anesthetic
4. Benefits of (type of procedure/surgery is named)
5. Unexpected Complications
6. General Risks of A Procedure
7. Risks of This Procedure
8. Patient Consent
9. Interpreter Statement
10. Doctor’s Statement

These sections represent information that is common to all consent forms and are presented in a consistent location with a consistent language. The form assumes a multilingual environment, with a box indicating whether an interpreter is needed and supports documentation of the process used to obtain an informed consent. The template with its simple writing results in consent forms that are easier to understand in English, thereby enhancing the opportunity to develop equally beneficial forms in Spanish or other languages.

After administrators and legal staff review the template, Temple is considering adopting the template approach to redesign and standardize consent forms.

The hope is that the use of a standardized template will result in forms that are easier to understand for all patients. Ultimately, these templates will be available through an on-line public repository as part of the Hablamos Juntos Resource Guide where health care institutions will be able to access them and thus improve the quality and consistency of their forms.

More on the Future Plans ...

In an effort to assist health care institutions in making better Spanish materials, Hablamos Juntos has expanded the translation brief, creating a new analytical tool that can be used to help determine whether translation is the best strategy for creating non-English materials.

Hablamos Juntos has found that in developing Spanish materials for health care settings, there is typically no attempt to explore the question of whether or not the content of the English document will achieve the document's intended communicative goal in a different cultural-linguistic framework. Materials given to an English-speaking patient are often assumed to be generally sufficient if translated for a LEP patient. However, in many cases, it may be necessary to modify the text, write new text from scratch, or use additional or alternative methods (i.e. audio recordings or images) to meet the needs of the new audience.

The translation brief should generally be filled out by the health facility staff member who oversees the production of non-English materials. The translation brief includes a description of the English original, its audience, how and who gives it to the patient and its intended use.

Next, health staff familiar with the use of the original document and with the new target population should participate in the analysis of how the experience of the LEP patient may be different and what communication needs these patients may have. This analysis should include strategic questions about the health knowledge and experiences of the target audience should be posed and answered.

• Have language barriers created circumstances that are different for the new audience?
• Are there health beliefs, customs or health seeking behaviors that are different for this population?
• Is the topic being reproduced in a different language a significant health issue among the target population?
• What are the literacy levels of the target population in order to determine whether the new document should be developed with more images than text?
• Are there any other special resources (i.e. interpreters) that the target population should be aware of?

This information is contrasted with the original to define the communication goals and content changes that may be needed in a translation.

Working with a translator, the analysis required by this tool should identify the information need differences a translation should consider or address and help determine whether a translated document should be attempted. The exercise can be used to distinguish between documents for which translation may or may not be effective and to provide detailed instructions for the translator who will help to adapt the materials for the new audience.

The primary goal of preparing a translation brief is to stimulate consideration of how the health care experience and information needs may be different for the new target audience. Ultimately, this tool allows health care organizations to better utilize its resources in producing materials that can actually be used by the new target population.

More on the Future Plans...

The University of North Texas Health Science Center, an Hablamos Juntos grantee located in Forth Worth, Texas, is working on an initiative to create a method of producing effective written materials in Spanish by avoiding translations.

“There was a scarcity of materials in Spanish on these topics, and the quality of the materials out there was poor,” said Dr. Holly Jacobson, Principal Investigator at UNTHSC. “Most of the materials are translated from English to Spanish, and the translations are falling short of the mark because they don’t meet the needs of the target population. They are basically lousy translations.”

In response to the idea that there are cases in which creating original materials in Spanish may be more effective than translation, Dr. Jacobson and her team at the Health Sciences Center have developed a 10-step process for developing original materials in Spanish.

“We are eliminating translating all together. We start by developing the materials to deliver health care messages from scratch in Spanish instead of starting in English and translating to Spanish.”

This process involves the participation of health writers, health communications consultants, and the health care providers and other entities that use the materials in their health care settings or disseminate the materials to clients and patients. More importantly, the materials development process is informed by the actual readers of the texts through field-testing.

The ten steps are as follows:

UNTHSC has teamed up with local health care organizations to create effective Spanish materials for a range of health care topics including breast cancer, colon cancer, diabetes, and birth control. At this point, 16 pieces have been developed and are now being reviewed by communications consultants (Step 7). Field-testing is set to begin in October 2005.

More on Grantees ...

Even though there is an acute need for trained interpreters in public services, there are few national codes of ethics and standards of practice for interpreters to use to guide their work. With funding from The Commonwealth Fund and The California Endowment, the National Council on Interpreting in Health Care has undertaken a project designed to lay the groundwork for national standards for medical interpreters.

The report, The Interpreter's World Tour: An Environmental Scan of Standards of Practice for Interpreters, has been published on The California Endowment Web site. In it, Marjory Bancroft, M.A., founder and director of Maryland-based Cross Cultural Communications, reviews standards of practice in interpreting within the U.S. and around the world. Among her findings:

Bancroft concludes that as a global leader in the interpreting profession, the United States "may bear a particular responsibility to develop national standards of practice for interpreters in health care."

More on the National Council on Interpreting in Health Care...

Language barrier can be a life or death issue

By Travis Loller, The Island Packet
Sunday, May 22, 2005

Brief:

SAVANNAH -- Tomás Xotla was working in New York when he received a telephone call Feb. 19 telling him his daughter was gravely ill. The two had come together to the United States from Mexico in April 2004, but Leticia Xotla Herrera had been away from him for four months, working in Savannah.

Xotla left for Savannah that same day, but by the time he arrived, his daughter was dead.

"There was no one to help her to say how she felt or what was wrong," Xotla said of Memorial Health University Medical Center, where Herrera was treated and later died. "Who was going to do that?"

Secretary of State site had translation errors

By Andrew Garber, Seattle Times Olympia bureau
Wednesday, January 26, 2005

Brief:

OLYMPIA — Debbie Hsu says something was lost in translation when Washington residents who speak Chinese tried to view the Secretary of State's Web site in their native language.

The Web site lets visitors view the site in different languages, but the Chinese translation was apparently way off. For example, a statement about Secretary of State Sam Reed proposing "statewide mandates to restore public trust" was translated as "Swampy weed suggests whole state order recover open trust," according to Hsu and others in the Section 203 Voting Rights Coalition.

For other stories, please visit the Hablamos Juntos Media Center...

The patient was a three-month old baby who had been born premature. He was brought in by his parents; a couple from Mexico in their mid 20's who had been living in a rural area of Alabama for about a year. The parents and the baby went to the Emergency Room because the baby was very lethargic. An interpreter was called to the ER because neither of the parents could speak English.

The doctor arrived quickly to attend this very sick baby. The mother told the doctor the baby’s history. After birth, the premature baby stayed in the neonatal intensive care unit for 15 days and there the doctor heard a murmur. The doctor had some concerns about the murmur he heard, so he scheduled the baby for a cardiac appointment two days after discharge at another hospital because this hospital does not have pediatric cardiology. The appointment was at a different hospital down the street. The mother went to the other hospital for the appointment and tried very hard to find the building and the office where the appointment was. She couldn't’t find it, so she asked one of the staff for an interpreter but nobody understood what she was saying and she was not able to communicate what she needed. So she left the hospital and went home. She continued to go to her regular check-ups with her pediatrician, but was unable to get another referral to the cardiologist.

Upon arrival to the ER the baby was examined and he had a serious cardio-respiratory problem due to a heart murmur. At this stage, it was too late to give the baby the treatment he needed because too much brain damage had already occurred. In this sad case, the baby died because he did not receive the proper medical attention and interventions early in life.

After the baby was admitted to the hospital, the same interpreter followed the patient and he also had a Spanish-speaking doctor during his hospitalization. So there was no longer a language barrier and the interpreter and doctor were able to communicate with the parents and help them cope with this difficult situation.

Tough to Swallow: Interpreters fix bilingual mistakes

An interpreter was called by the Department of Endocrinology. When the interpreter arrived, there was a very young mother, Maria, with her child, Jose. It happened that after speaking with Maria, the interpreter found out that they were both Venezuelan and what’s more, the doctor who was doing the assessment did part of his residency in Venezuela.

When the doctor finished examining Jose, he said in Spanish, “Maria, le debes dar una pastilla de esta medicina a José una vez al día. Como puedes ver es muy pequeña y él puede tragar.” (Maria, you have to give Jose one pill of this medication once a day. As you can see, it is very small and he will be able to swallow it.”) The doctor then recounted to the patient and interpreter the story of a previous encounter in which, thinking he did not need an interpreter, he told a patient in Spanish, “You have to take one patilla once a day. It is very small and you will be able to swallow it.” In this story, the patient turned red and left very upset. To figure out why, the doctor asked a nurse who had witnessed the encounter. She laughed and told him, “You said ‘patilla’ which means ‘watermelon.’ You just asked the patient to swallow a watermelon!” Since then the doctor has understood the importance of a good interpreter while examining a limited English proficiency patient.

That day Maria was properly instructed to give one very small pill to her son, and despite her baby’s illness, they all shared a good moment together.

More on Vignettes...

Hablamos Juntos (Spanish for "We Speak Together") is a unique project designed to forge connections between health care providers and the rapidly growing Latino health market. As a national program of the Robert Wood Johnson Foundation, Hablamos Juntos is investing $10 million in ten demonstration sites around the country. These sites, ranging from health plans and large hospital systems to small nonprofit community organizations, will work to improve communication between health care providers and patients and eliminate language barriers that can lead to medical errors and compromise the quality of care.

More on Hablamos Juntos...