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Literature, papers, reports, and data

This section includes papers and reports gathered and produced during the planning and implementation phases of Hablamos Juntos. These materials represent what was known at the time the reports were written, but may not reflect the program’s final findings, which will be available on this website in September 2005.

These papers, reports, and data fall into the following categories:

The State of Health Care for LEP

1.26 "The National Standards for Culturally and Linguistically Appropriate Services in Health Care” The Care Management Journals, Volume 3, Number 2, pages 77 – 83, 2002.   This article describes each of the 14 (CLAS) standards that were published in December 2000 by the Office of Minority Health.  It also suggests strategies for meeting the cultural and linguistic needs of home health care patients.

1.25 Adam L. Cohen, MD, MPH; Frederick Rivara, MD, MPH; Edgar K. Marcuse, MD, MPH; Heather McPhillips, MD, MPH; and Robert Davis, MD, MPH. (September 2005). Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients?

1.24 Andrulis, Dennis PhD, Nanette Goodman MA and Carol Pryor MPH. (April 2002). What A Difference An Interpreter Can Make, Health Care Experiences of Uninsured with Limited English Proficiency. The Access Project .

1.23 Bethell, Christina PhD, MPH, MBA, Kim Carter, MS, David Lansky, PhD, Brooke Latzke, Kris Gowen, PhD. (March 2003). Measuring and Interpreting Health Care Quality Across Culturally-Diverse Populations: A Focus on Consumer-Reported Indicators of Health Care Quality. FACCT-Foundation for Accountability.

1.22 Lisa A. Cooper and Neil R. Powe. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient–Provider Racial, Ethnic, and Language Concordance. (July 2004). The Commonwealth Fund.

1.21 Kaiser Commission on Medicaid and the Uninsured – Policy Brief. (August 2003). Disparities in Health Coverage, Access, and Quality: The Impact of Citizenship Status and Language on Low-Income Immigrants. This brief examines the roles of race/ethnicity, citizenship, and language on insurance coverage, access to care, and quality of care, with a focus on the low-income Latino population.

1.20 Flores, Glenn, M.D., Abreu, Milagros, M.D., and Sandra C. Tomany-Korman, M.S. (July 2005). Limited English Proficiency, Primary Language at Home, and Disparities in Children’s Health Care: How Language Barriers are Measured Matters. Public Health Reports, 120 (4): 418–30. This brief report summarizes the Commonwealth Fund study’s findings and concludes that LEP is more useful than language spoken at home in gauging the impact of language barriers in children’s health care.

1.19 Flores, Glenn, M.D., Laws, M. Barton, Ph.D., Mayo, Sandra J., Ed.M., Zuckerman, Barry M.D., Abreu, Milagros M.D., Medina, Leonardo M.D., and Eric J. Hardt, M.D. (January 2003). Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. American Academy of Pediatrics 111.1: 6-14.

1.18 Flores, Glenn, et al. (1998). Access Barriers to Health Care for Latino Children. Archive of Pediatric Adolescent Medicine. November. 152(11):1119-1125).

1.17 Hasnain-Wynia Romana, Debra Pierce, and Mary A. Pittman (May 2004). Who, When, and How: The Current State of Race, Ethnicity, and Primary Language Data Collection in Hospitals. Health Research and Educational Trust - The Commonwealth Fund.

1.16 Health Disparities Experienced by Hispanics -- United States. (October 2004). Morbidity and Mortality Weekly Report, Centers for Disease Control. 53(40);935-937

1.15 Elizabeth A. Jacobs, MD, MPP, Alice HM Chen, Leah S. Karliner, MD, Niels Agger-Gupta, and Sunita Mutha. (2006). The Need for More Research on Language Barriers in Health Care: A Proposed Research Agenda. The Milbank Quarterly, Vol. 84, No. 1. This article describes what is currently known about language barriers in health care and outlines a research agenda based on mismatches between the current state of knowledge of language barriers and what health care stakeholders need to know.

1.14 Elizabeth A. Jacobs, MD, MPP; Kelly Karavolos, MA; Paul J. Rathouz, PhD; Timothy G. Ferris, MD, MPH; and Lynda H. Powell, PhD. (August 2005). Limited English proficiency and breast and cervical cancer screening in a multiethnic population.

1.13 Leah S. Karliner, MD, Eliseo J. Pérez-Stable, MD, Ginny Gildengorin, PhD. (February 2004) The Language Divide, The Importance of Training in the Use of Interpreters for Outpatient Practice. Journal of General Internal Medicine, Volume 19:175–183. Communication difficulties affect the ability of physician residents to understand symptoms and treat disease, as well as their ability to empower patients regarding their healthcare. The study concludes that training providers in the use of interpreters may improve communication and clinical care, and thus health outcomes.

1.12 Kaiser Family Foundation. (October 1999). Key Facts Race, Ethnicity & Medical Care. The Henry J. Kaiser Family Foundation. A quick reference source on health, health coverage and health care use of minority Americans.

1.11 Ku, L. and T. Waidmann. (August 2003). How Race/Ethnicity, Immigration Status and Language Affect Health Insurance Coverage, Access to Care and Quality of Care Among the Low-Income Population. The Kaiser Commission on Medicaid and the Uninsured.

1.10 Lake, Snell and Perry Associates Inc. (March 2004) Physician Perspectives on Communication Barriers Insights from Focus Groups with Physicians Who Treat Non-English Proficient and Limited English Proficient Patients (Executive Summary). Lake, Snell and Perry Associates Inc. A study sponsored by The Robert Wood Johnson Foundation –Hablamos Juntos.

1.9 Lake, Snell and Perry Associates Inc. (March 2004) Physician Perspectives on Communication Barriers Insights from Focus Groups with Physicians Who Treat Non-English Proficient and Limited English Proficient Patients (Full Report). Lake, Snell and Perry Associates Inc. A study sponsored by The Robert Wood Johnson Foundation –Hablamos Juntos. Physicians, we welcome your feedback related to this report.

1.8 National Healthcare Disparities Report. (2005). U.S. Department of Health and Human Services - Agency for Healthcare Research and Quality.

1.7 National Healthcare Disparities Report. (2003). U.S. Department of Health and Human Services - Agency for Healthcare Research and Quality.

1.6 Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson, Editors. (2003) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. The National Academies Press. The report found that U.S. racial and ethnic minorities are less likely to receive even routine medical procedures and experience a lower quality of health services. These conclusions are supported by a consistent body of research demonstrates significant variation in the rates of medical procedures by race, even when insurance status, income, age, and severity of conditions are comparable.

1.5 Unequal Treatment. Unequal Health. What Data Tell Us About Health Gaps in California. This publication is a joint effort by the National Academy of Science’s Institute of Medicine, Cause Communications and The California Endowment. The publication highlights findings from a study requested by Congress entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, published in 2002 by the Institute of Medicine (IOM).

1.4 Vandervort, E.B. and G.D. Melkus. “Linguistic Services in Ambulatory Clinics.” (October 2003). Journal of Transcultural Nursing 14.4: 358-366. This article describes a survey of language services offered by community health and the results. Although most of the clinics provided informal mechanisms of interpreter services, few directly addressed linguistic services as a component of culturally competent care.

1.3 Elisabeth Wilson, MD, MPH, Alice Hm Chen, MD, MPH, Kevin Grumbach, MD, Frances Wang, MS, Alicia Fernandez, MD. (April 2005). Effects of Limited English Proficiency and Physician Language on Health Care Comprehension. This publication explores the effect of limited English proficiency on medical comprehension in the presence and absence of language-concordant physicians. The study describes differences in medical comprehension between LEP and English-proficient respondents from a large, linguistically diverse population based sample, and found that LEP individuals report more difficulty understanding medical situations and medication use than their English proficient counterparts, but that access to a language concordant physician substantially reduces the risk of comprehension problems among LEP individuals.

1.2 Wirthlin Worldwide. (2001). Hablamos Juntos: We Speak Together, Final Report. Research conducted for the Robert Wood Johnson Foundation on patient and provider perspectives on language barriers.

1.1 Wirthlin Worldwide. (October/November 2001) Hablamos Juntos - We Speak Together (power point). Research conducted for the Robert Wood Johnson Foundation on patient and provider perspectives on language barriers.

Population Change and Language Data


An easy-to-use tool, developed by the Social Science Data Analysis Network (SSDAN) at the University of Michigan, for investigating U.S. demographic trends by geography at different levels (states, metro areas, and counties) and to produce charts and exportable trend data from Ability to Speak English Among Those Speaking A Language Other Than English, 2000 Census data. http://www.censusscope.org.

Modern Language Map:

An easy-to-use map developed by the Modern Language Association to display the locations (state, county and zip code) and numbers of speakers of the thirty languages most commonly spoken in the United States. Also uses 2000 Census data. http://www.mla.org/

Growth in the Latino Population (1990 - 2000)

Click on your state for a full listing of county level population data.

2.8 Frey, William H. (October 2003). Metropolitan Magnets for International and Domestic Migrants. The Brookings Institution Center on Urban and Metropolitan Policy.

2.7 Hablamos Juntos. (December 2001). Population Change for Hispanics from 1990 to 2000 by State - Fact sheet . the Robert Wood Johnson Foundation – Hablamos Juntos.

2.6 U.S. Census. (October 2003). Language Use and English-Speaking Ability: 2000. Census 2000 Brief.

2.5 Medical School Graduates by race and ethnicity. StateHealthFacts.org has updated the race/ethnicity data for medical school graduates to 2004 and include new data on Hispanic medical school graduates by state and region. Statehealthfacts.org, from the Henry J. Kaiser Family Foundation, provides free, up-to-date, and easy-to-use health and health policy data on all 50 states. Statehealthfacts.org has data on more than 500 health topics including Medicaid and SCHIP, Medicare, health coverage and the uninsured, health costs and budgets, providers and service use, minority health, women's health, and HIV/AIDS.

2.4 National Clearinghouse for English Language Acquisition (NCELA) (2000) Poster-English Language Learners & The U.S. Census 1990-2000. U.S. Department of Education – Office of English Language Acquisition, Language Enhancement and Academic Achievement for Limited English Proficient Students. New Jersey Pennsylvania Connecticut and Rhode Island New York Massachusetts Vermont and New Hampshire Maine Virginia West Virginia Maryland and Delaware Georgia Florida South Carolina North Carolina Louisiana Ohio Kentucky Indiana Tennessee Mississippi Alabama Michigan Wisconsin Arkansas Missouri Illinois Iowa Minnesota Oklahoma Kansas Nebraska South Dakota North Dakota Texas New Mexico Colorado Arizona Wyoming Utah Montana Idaho Nevada Alaska and Hawaii California Oregon Washington

2.3 Marsha Regenstein, PhD and Donna Sickler, MPH (January 2006). Race, Ethnicity and Language of Patients Hospital Practices Regarding Collection of Information to Address Disparities in Health Care. The study was conducted by the National Public Health and Hospital Institute (NPHHI) with support from The Robert Wood Johnson Foundation.

2.2 Audrey Singer and Jill H. Wilson, Polyglot Washington: Language Needs and Abilities in the Nation’s Capital, Brookings Institute (2004)

2.1 Suro, Roberto, and Jeffrey S. Passel. (October 2003). The Rise of the Second Generation: Changing Patterns in Hispanic Population Growth . Pew Hispanic Center.

The Business Case for Language Access

3.7 Assessment of the Total Benefits and Costs of Implementing Executive Order No. 13166: Improving Access to Services for Persons with Limited English Proficiency, Report to Congress, Office of Management and Budget (March 14, 2002).

3.6 Bailit, Michael and Mary Beth Dyer (2004). Beyond Bankable Dollars: Establishing a Business Case for Improving Health Care. The Commonwealth Fund.

3.5 Brach C and Irene Fraser. (2002). Reducing Disparities through Culturally Competent Health Care: An Analysis of the Business Case. Quality Management in Health Care. No. 10 (4), 15-28.

3.4 Markian Hawryluk, Lost in Translation: Ways to Afford Speaking Your Patients’ Languages, American Medical News (Dec. 2, 2002).

3.3 Jacobs, Elizabeth A., M.D., M.P.P., Shepard, Donald S., Ph.D., M.P.P., Suaya, Jose A., M.D., M.B.A., and Esta-Lee Stone, M.S., OTR/L. (May 2004). Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health 94.5.

3.2 Rollins, Gina. (Spring 2002). Language Services in Public Hospitals: Limited Budget, Unlimited Support. National Association of Public Hospitals and Health Systems - The Safety Net 16.1: 22-25. Describes results of organization and community outreach for Rancho Los Amigos National Rehabilitation Center, an award-winning center.

3.1 Struggle to Communicate: Medical Interpretation in Arizona, Arizona Health Futures (April 2004). Note: AHF is the policy and research arm of Phoenix-based St. Luke’s Health Initiatives. This document includes several pages on approaches to funding medical interpreting services.

Legal Requirements and Government Policy Related to Language Access

4.11 National Health Law Program. (2002). Assessment of State Laws, Regulations and Practices Affecting the Collection and Reporting of Racial and Ethnic Data by Health Insurers and Managed Care Plans: Preliminary Findings: Phase I: Executive Summary. National Health Law Program - US Department of Health and Human Services – Office of Minority Health.

4.10 Marsha Lillie-Blanton and Caya B. Lewis. Policy Challenges and Opportunities in Closing the Racial/Ethnic Divide in Health Care. (March 2005). Kaiser Family Foundation Policy Brief.

4.9 Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (revised). (August 2003). U.S. Department of Health and Human Services.

4.8 Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. (June 18, 2002). U.S. Department of Justice, Federal Register, Vol. 67, No. 117:41455-41472.

4.7 Hablamos Juntos. (November 2002). Workforce Investment Act. the Robert Wood Johnson Foundation – Hablamos Juntos. This report provides information on the Workforce Investment Act and examples of communities using these funds for health professions training. This is a potential resource for health interpreter training programs.

4.6 Language Services Action Kit - Interpreter Services In Health Care Settings For People With Limited English Proficiency. (February 2004). The Access Project and the National Health Law Program. An Action Kit for advocates and others working to ensure that people with limited English proficiency in their state get appropriate language assistance services in medical settings. (English and Spanish versions).

4.5 U.S. Department of Health and Human Services (March 2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care: FINAL REPORT. U.S. Department of Health and Human Services –Office of Minority Health.

4.4 This video created by the Office for Civil Rights describes the legal principles guiding the provision of language services as stipulated by Title VI of the Civil Rights Act of 1964 and its prohibition against discrimination on the basis of national origin including limited English proficiency. The video explains the factors needed to provide meaningful access to programs and services by recipients of federal funding and portrays examples of language services.

4.3 Perkins, Jane, J.D., M.P.H. (August 2003). Ensuring Linguistic Access in Health Care Settings: An Overview of Current Legal Rights and Responsibilities. National Health Law Program-The Henry J. Kaiser Family Foundation – Kaiser Commission on Medicaid and the Uninsured.

4.2 Perkins, Jane, J.D., M.P.H., Youdelman, Mara, J.D., LL.M., and Doreena Wong. (August 2003). Ensuring Linguistic Access in Health Care Settings: Legal Rights & Responsibilities.

4.1 Dr. Dirk G. Schroeder, ScD, MPH. Emory University School of Public Health. (June 2002). Limited English Proficiency (LEP) Regulations: Implications and Guidance for U.S. Hospitals Serving Minority Populations. This paper provides a summary explanation of Federal Limited English Proficiency (LEP) regulations. It also describes recent lawsuits brought against hospitals based on LEP regulations and provides guidance on ways hospitals can ensure their compliance with LEP regulations. A descriptive case study applying these concepts is also included.

Organizational Approaches to Language Access

5.15 Cindy Brach, Irene Fraser, and Kathy Paez. Crossing the Language Chasm. Health Affairs 24 (March/April 2005): 424-434.

5.14 National Association of State Workforce Agencies. (January 2004). Checklist for Developing a Limited English Proficiency (LEP) Plan.

5.13 Downing, Bruce T., Ph.D., and Cynthia E. Roat, MPH (January 2002). Models For The Provision Of Language Access In Health Care Settings. the Robert Wood Johnson Foundation - Hablamos Juntos.

5.12Annette Fuentes, Condition Critical: The Absence of Latinos Among Policymakers in New York City’s Voluntary Hospitals, Puerto Rican Legal Defense and Education Fund (December 2004). Note: Study funded in large part by the W.K. Kellogg Foundation.

5.11 Language Access Resources, 2002-2004 Proceedings of the Medical Leadership Council on Language Access. [Note: The Medical Leadership Council, founded by The California Endowment and convened annually by the California Academy of Family Physicians (CAFP), consists of some 28 organizations working to develop strategies for financing and delivering interpreter and translation services to LEP Californians.]

5.10 The Interagency Working Group on LEP. Language Assistance Self-Assessment and Planning Tool for Recipients of Federal Financial Assistance. Civil Rights Division, Department of Justice, Washington, DC.

5.9 Language Barriers to Health Care. (2005). Medical Journal, official publication of the Medical Society of Delaware.

5.8 Making Language Services a Reality 2005 Child Health Services Research Meeting. (2005). National Health law Program. This PowerPoint Presentation from the National Health Law Program describes current strategies and potential approaches to make the provision of language services a practical and affordable reality. The report includes information on available models including reimbursement mechanisms, partnerships, and community based initiatives; and provides guidance for language services implementation strategies at different levels.

5.7 Mateo, Julio, and Elia V. Gallardo. (February 2004). Providing Health Care to Limited English Proficient (LEP) Patients: A Manual of Promising Practices. California Primary Care Association.

5.6 National Study of Culturally and Linguistically Appropriate Services in Managed Care Organizations, Cosmos Corporation for the Office of Minority Health, US Department of Health and Human Services (August, 2003)

5.5 Kathryn Paez and Margaret Gunter, Planning Culturally and Linguistically Appropriate Services: A Guide for Managed Care Plans, Centers for Medicaid and Medicare Services, HHS (February, 2003).

5.4 Promising Practices in Healthcare. Language Access Advocacy Project California 2004.

5.3 Providing Oral Linguistic Services: A Guide for Managed Care Plans, Centers for Medicare and Medicaid, HHS (February, 2003).

5.2 Robert Putsch et al., Cross Cultural Health Care Program, Reflections on the CLAS Standards: Best Practices, Innovations and Horizons (October, 2003)

5.1 Mara Youdelman, J.D., and Jane Perkins, J.D. (April 2005). Providing Language Services in Small Health Care Provider Settings: Examples from the Field. The Commonwealth Fund.

Interpreters and Interpreting

6.25 Angelelli, Claudia. (2004). Medical Interpreting and Cross-cultural Communication. Cambridge University Press. Bringing together literature from social theory, social psychology, and linguistic anthropology, this first ever ethnographic study of a bilingual hospital explores the role of medical interpreters, drawing on data from over 300 medical encounters and interviews with health interpreters, their challenges, and how they characterize their role. Traditionally the interpreter has been viewed as a language conduit, with little power over the medical encounter or the relationship between patient and provider. This book presents an alternative view, considering the interpreter’s agency and contextualizing the practice within an institution that is part of a larger society.

6.24 Angelelli, Claudia. (2004). Revisiting the Interpreter’s Role, A study of conference, court, and medical interpreters in Canada, Mexico, and the United States. Benjamins Translation Library. The book reports on a study of the role that interpreters play in the various settings where they work, i.e. the courts, the hospitals, business meetings, international conferences, and schools. It presents interpreter's perceptions and beliefs about their work as well as statements of their behaviors about their practice as well as the administration and results of a survey administered across languages in Canada, Mexico and the United States.

6.23 Angelelli, Claudia. (2000). Interpretation Pedagogy: A Bridge Long Over Due. ATA Chronicle. November/December. Please note that this article is only available electronically if you are a member of the ATA.

6.22 Avery, Maria-Paz Beltrán, Ph.D., Chun, Ann, Downing, Bruce, Ph.D., Maynard, Marcia, R.I.D., and Karin Ruschke, M.A. (April 2001). Guide to Initial Assessment of Interpreter Qualifications. The National Council on Interpreting in Health Care: Working Papers Series.

6.21 Avery, Maria-Paz Beltrán, Ph.D. (April 2001). The Role of the Health Care Interpreter: An Evolving Dialogue. The National Council on Interpreting in Health Care: Working Paper Series.

6.20 BA in Translation and Interpretation Studies English/Spanish at CSULB. This document provides information on training programs and content curricula on Interpreting and Translation.

6.19 Marjory Bancroft , MA . The Interpreter's World Tour: An Environmental Scan of Standards of Practice for Interpreters. (March 2005). The California Endowment, prepared for the National Council on Interpreting in Health Care.

6.18 Standards of Practice for Interpreters. An Environmental Scan. Marjory Bancroft, MA. (March 2004). The National Council On Interpreting In Health Care Working Papers Series - The Commonwealth Fund and The California Endowment.

6.17 California Standards for Healthcare Interpreters, Ethical Principles, Protocols, and Guidance on Roles & Intervention. (2002). California Healthcare Interpreters Association - The California Endowment.

6.16 Hablamos Juntos. (October 2002). Interpreter Training Programs. the Robert Wood Johnson Foundation – Hablamos Juntos. This report includes examples of medical interpreter training programs in a summary table and a narrative description with contact information and student cost.

6.15 Hablamos Juntos. (September 2002). Language Testing Options. the Robert Wood Johnson Foundation – Hablamos Juntos. A list of language proficiency and interpreting skill testing options provided for informational purposes only and not intended to imply any endorsement, recommendation or approval. The absence of health specific testing tools prompted Hablamos Juntos to pilot test a set of assessment tools in the demonstration sites.

6.14 Haffner, Linda, Karin Ruschke, MA, Shiva Bidar-Sielaff, MPH, Maria-Paz Avery, PhD; Bruce Downing, PhD; Carola Green; and Cynthia Roat, MPH. (November 2003). Guide To Interpreter Positioning In Health Care Settings. National Council on Interpreting in Health Care Working Papers Series.

6.13 Interpreter Training Resources. On this page you will find a brief introduction to some of the more useful texts published on simultaneous interpreting.

6.12 Sharon M. Lee, Ph.D. and Clyde R. Pope, Ph.D., Patients Who Don’t Speak English: Improving Language Minorities’ Health Care with Professional Interpreters, Office of Minority Health, US Department of Health and Human Services (October, 2001).

6.11 Massachusetts Department of Public Health Office. Best Practice Recommendations for Hospital-Based Interpreter Services. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Massachusetts Department of Public Health Office of Minority Health. This reference guide is designed to assist acute care hospitals develop interpreter services consistent with the state.

6.10 Massachusetts Medical Interpreters Association.
Code of Ethics

6.9 Matthews, Clair, Johnson, Maree, Noble, Cathy, and A. Whelan/Kinklen. (January 2000). Bilingual Health Communicators: Role Delineation Issues. Australian Health Review 23.3: 104-112. This paper examines key features of the roles of interpreters and bilingual communication facilitators (scope of language, language proficiency, nature of communication/interaction, nature of the contact and relationship, client responsibilities, and relationship with other health care providers) and the differences in how bilingual health staff use language when providing care, and offers to extend the role of interpreter.

6.8 Models for the Provision of Health Care Interpreter Training. National Council for Interpreters in Health Care. (February 2002).

6.7 Monroe, Alicia D., and Taraneh Shirazian. (February 2004). Challenging Linguistic Barriers To Health Care: Students As Medical Interpreters. Academic Medicine 79.2: 118-122. Describes an interpreter aide program using bilingual undergraduate and medical students trained as medical interpreters implemented at Brown Medical School in 1997 to expand interpreter services to Spanish and Portuguese-speaking patients at Rhode Island Hospital.

6.6 National Code of Ethics for Interpreters In Health Care. (July 2004). The National Council On Interpreting In Health Care Working Papers Series - U.S. DHHS Office for Minority Health.

6.5 National Standards of Practice for Interpreters in Health Care. (September 2005). The California Endowment, prepared for The National Council On Interpreting In Health Care. This publication explains the context in which the standards were developed, describes the process of development and suggests ways in which the standards can be used.

6.4 Paras, Melinda, Obiel A. Leyva M.P.H., Tim Berthold M.P.H., Raymond N. Otake J.D. (April 2002). Videoconferencing Medical Interpretation: The Results of Clinical Trials. Health Access Foundation.

6.3 Roat, Cynthia E. M.P.H. (February 2003). Health Care Interpreter Training in the State of California Including an Analysis of Trends and a Compendium of Training Programs. The California Endowment . A survey of 21 health care interpreter training programs in California to analyze current trends in interpreter training and to produce a compendium of programs as a resource for those seeking training.

6.2 Saint-Louis, Loretta, Ph.D., Friedman, Elisa, M.P.H., Chiasson, Emily, M.S.W., M.P.H., Quessa, Avlot, and Fernando Novaes. (June 2003). Testing New Technologies in Medical Interpreting. Cambridge Health Alliance: a Community of Caring. A study comparing four methods of providing interpreter services: traditional face-to-face, speakerphone, videoconferencing, and remote simultaneous interpreting equipment. Contrary to provider assumptions, patients are open to using technology for interpreting and, in many cases, preferred it.

6.1 Torres, Brunilda. (February 2004). Best Practice Recommendations for Hospital-Based Interpreter Services. Commonwealth of Massachusetts, Executive Office of Health and Human Services.

Translation and Quality Written Materials

7.17 The following documents provide information on training programs and content curricula on translation:

7.16 Andrew C. Bernard, MD, Audra Summers, RN, Jennifer Thomas, RN, Myrna Ray, MS, Anna Rockich, PharmD, Stephen Barnes, MD, Bernard Boulanger, MD, Paul Kearney, MD. (November 2005). Novel Spanish Translators for Acute Care Nurses and Physicians: Usefulness and Effect on Practitioners' Stress. This paper evaluates the effectiveness of a novel English-Spanish translator designed specifically to nurses and physicians. This report links communication barriers with stress levels among nurses and physicians caring for Spanish speaking patients.

7.15 This web repository is a compilation of over 300 health care documents that are translated into Los Angeles County’s ten threshold languages (Armenian, Chinese, English, Farsi, Khmer, Korean, Russian, Spanish, Tagalog, and Vietnamese). This serves to assist providers in better communicating with their LEP patients.

7.14 Cabrera, D.M., Morisky, D.E., and S. Chin. (February 2002). Development of a tuberculosis education booklet for Latino immigrant patients. Patient Education and Counseling 46.2: 117-124. Describes the stages used to develop a culturally sensitive TB education pamphlet for a low-literate Spanish-speaking immigrant population.

7.13 Colina, Sonia. (2003). Translation Teaching: From Research To The Classroom – A Handbook for Teachers. New York, San Francisco: McGraw Hill Second Language Professional Series.

7.12 Cornelio, Maria (2003).  ‘Health Literacy’ and the Medical Translator.  Apuntes, InTradES's quarterly publication, contains original articles, interviews, reference material and useful information for language professionals working with English and Spanish. http://spansig.org/Translation/apuntesdisplay.html

7.11 Cornelio, Maria (2003). Beware of the 'Bilingual Expert'.  ATA Chronicle (the journal of the American Translator Association).  August, Vol. 3 No. 8

7.10 Downing, Bruce T., Ph.D., and Laurence H. Bogoslaw, Ph.D. (April 2003) Translation as a Strategy for Effective Communication with Patients and Clients: A How-To Guide. the Robert Wood Johnson Foundation – Hablamos Juntos.

7.9 Downing, Bruce T., Ph.D., and Laurence H. Bogoslaw, Ph.D (February 2003). Effective Patient-Provider Communication Across Language Barriers: A Focus on Methods of Translation . The Robert Wood Johnson Foundation - Hablamos Juntos.

7.8 Givaudan, Martha, Pick, Susan, De Venguer, Ma. Teresa T. and Ulises Xolocotzin. (October 2003). Development of an Instrument to Test the Cultural Adequacy of Health Related Written Material for Latinos in the USA. The Robert Wood Johnson Foundation – Hablamos Juntos.

7.7 Givaudan, Martha, Pick, Susan, De Venguer, Ma. Teresa T. and Ulises Xolocotzin. (October 2002). Bridging the Communication Gap: Provider to Patient Written Communication Across Language and Cultural Barriers. The Robert Wood Johnson Foundation – Hablamos Juntos.

7.6 Jacobson, Holly, PhD. (January 2004). Ten Principles for Developing Effective Spanish Health Written Materials. University of North Texas Health Science Center, School of Public Health – Háblenos de Su Salud.

7.5 Jacobson, Holly E., Ph.D. (2003). Translation of the Health Brochure and Impact on the Target Reader: a Contrastive Analysis of the Structural and Pragmatic Features of Texts Translated into Spanish versus Texts Written Originally in Spanish. Ph.D. Dissertation. University of Arizona.

7.4 Kay, Martin. "Machine Translation." Linguistic Society of America website. (December 2004).

7.3 Koval, Alejandra (August 2004). Cultural Competency and Translation for Research. The ATA Chronicle.

7.2 Masset, H.A. (June 1996). Appropriateness of Hispanic Print Materials: A Content Analysis. Health Education Research 11.2: 231-242. This paper discusses the results of a content analysis of 26 national print breast cancer educational artifacts distributed to Hispanic women. The purpose was to assess the linguistic appropriateness and cultural sensitivity of the materials in efforts to establish preliminary guidelines for the development of future materials. All 26 failed to include components essential to reaching and impacting the designated target audience.

7.1 Moreno, Carmen; Matilde Alvarado; Hector Balcazar; Clare Lane; Hielen Newman, Gloria Ortiz, and Maxine Forrest. (1997). Heart Disease Education and Prevention Program Targeting Immigrant Latinos: Using Focus Group Responses to Develop Effective Interventions. Journal of Community Health, Vol. 22: No. 4. December.


8.8 Berger, Craig (December 2005). Universal Symbols In Health Care Workbook, Best Practices for Sign Systems. the Robert Wood Johnson Foundation - Hablamos Juntos and Society for Environmental Graphic Design (pending release).

8.7 Test methods for judged comprehensibility and for comprehension. (December 2001). ISO Bulletin. Jeremy J. Foster. Manchester Metropolitan University. United Kingdom.

8.6 ISO in brief: International Standards for a Sustainable World (2005). International Organization for Standardization (ISO).

8.5 Massachusetts Department of Public Health. Poster Notice - Interpreter Availability at no cost. Contains the following message in 31 languages: - You have a right to a medical interpreter at no cost to you. Please point to your language. A medical interpreter will be called. Please wait. Can be downloaded free.

8.4 State of Florida. Poster Notice - Interpreter Availability at no cost. Contains the following message in 21 languages: Attention! If you do not speak English, or if you are deaf, hard of hearing, or sight impaired, YOU can have interpretive and translation services provided at no charge. Please ask for assistance. Can be downloaded free.

8.3 Symbol Usage In Health Care Settings for People with Limited English Proficiency.  This three-part paper, prepared by JRC Design in consultation with Hablamos Juntos and SEGD and others, documents the conceptualization and development of universal symbols for health care.

Part One: Evaluation Of Use Of Symbol Graphics In Medical Settings. (April 2003) Bolek, Jim. JRC Design. the Robert Wood Johnson Foundation - Hablamos Juntos.  Provides a history of symbols use as well as an overview of the exisiting use of symbols in a healthcare setting.

Part Two: Implementation Recommendations. (April 2003) Bolek, Jim. JRC Design. the Robert Wood Johnson Foundation - Hablamos Juntos. Provides suggestions for the development and testing symbols for health care.

Part Three: Symbols Design Technical Report. Cowgill Jamie, Jim Bolek, Wendy T. Olmstead, Craig Berger, Phil Garvey (September 2005) the Robert Wood Johnson Foundation - Hablamos Juntos and Society for Environmental Graphic Design.  Summarizes the symbol development and testing process resulting in 28 health care symbols, contains the forms and resources used in testing.

Other Signage Resources


Dewar, Robert. “Design and evaluation of public information symbols.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.). 292. Taylor & Francis Inc. 1999.

Brugger, Christof. “Public information symbols: a comparison of ISO testing procedures.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.). 292. Taylor & Francis Inc. 1999.

Olmstead, Wendy T. “The usability of symbols for health care facilities: the effects of culture, gender and age.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.).

Harm J. G. Zwaga, Theo Boersema and Henriette C. M. Hoonhout, editors. (1999) Visual Information for Everyday Use: Design and Research Perspectives. London: Taylor & Francis, 1999. 328 pp.


Haq, S. and Zimring, C. (January 2003). Just down the road a piece: The development of topological knowledge of building layouts. Environment and Behavior, Vol. 35 No. 1, pp 132-160.

O’Neill, M.J. (1991b). Evaluation of a conceptual model of architectural legibility. Environment and Behavior, Vol. 23 No. 3, pp 259-284.

O’Neill, M.J. (1991a). Effects of signage and floor plan configuration on wayfinding accuracy. Environment and Behavior, Vol. 23 No. 5, pp 553-574.

Lawton , C.A., Charleston, S.I., and Zieles, A.S. (1996). Individual and gender-related differences in indoor wayfinding. Environment and Behavior. Vol. 28, No. 2, pp 204-219.

Talbot, J.F., Kaplan, R., Kuo, F.E., and Kaplan, S. (1993). Factors that enhance effectiveness of visitor maps. Environment and Behavior, Vol. 25 No. 6, pp 743-760.

Ethics and Culture

9.3 Cultural Competence in Health Care: Is it important for people with chronic conditions? (February 2004) Center on an Aging Society, Georgetown University.

9.2 Howard, C.A., Andrade, S.J., and T. Byrd. (January 2001). The Ethical Dimensions Of Cultural Competence In Border Health Care Settings. Family & Community Health 23.4: 36-49 . This article challenges the commonly understood definition of culture. It explores areas of concern related to cultural competency and medical ethics.

9.1 Improving Cultural Competency in Children's Health Care: Expanding Perspectives. (July 2005). The National Initiative for Children's Healthcare Quality (NICHQ). This report examines steps to address disparities in children's health care and to advance the ability of organizations to provide culturally competent care.


10.2 Research in Medical Interpretation: Bibliography. Hardt, Eric, M.D. (April 2001) The National Council on Interpreting in Health Care.

10.1 Language Barriers in Health Care Settings: An Annotated Bibliography of the Research Literature. Jacobs, Elizabeth A., M.D., M.P.P., Agger-Gupta, Niels, Ph.D., Chen, Alice Hm, M.D., M.P.H., Piotrowski, Adam, and Eric J. Hardt, M.D. (August 2003) The California Endowment: A Partner for Healthier Communities.

Training Tools

11.2 Grainger-Monsen, Maren M.D., and Julia Haslett. (2003) Worlds Apart: A Four-Part Series on Cross-Cultural Health Care. Funded by The Commonwealth Fund. A series of short films documenting the experiences of U.S. and foreign born minority patients in the U.S. health care system. The films capture communication challenges between patients and their doctors, tensions between modern medicine and cultural beliefs, and the ongoing burdens of racial and ethnic discrimination. Film clips and the study guide are available on this site.

11.1 Online Training for Doctors on Working with Interpreters. This program, developed by Cindy Roat and Dr. Liz Jacobs, confers up to 2½ CME credits through Rush Medical College. It uses video and case studies to train doctors on: how to work with professional interpreters, how to guide an untrained interpreter, how to work with a telephonic interpreter, how to work with interpreters in mental health settings, and how to start to develop a language access program internal to a hospital or clinic. The program costs $15 per credit, and there are discounts available for bulk orders. For more information, contact Cindy Roat.


English Dictionary - Merriam-Webster English Dictionary Online.

English-French-Spanish Glossary of Food Items [Part 1 (A-F)] [Part 2 (G-Z)] . The Food and Agriculture Organization of the United Nations.

English-Spanish Dictionary of Health Related Terms. (June 2003). California Policy Research Center – California-Mexico Health Initiative, California Department of Health Services – California Office of Binational Border Health. The California Endowment.

Real Academia de la Lengua Espanola - Spanish Dictionary and Other Resources.

Ruschke, Karin, M.A., Haffner, Linda, Downing, Bruce, Ph.D., Avery, Maria-Paz Beltrán, Ph.D., and Marcia Maynard, R.I.D. (October 2001). The Terminology of Health Care Interpreting: A Glossary of Terms. The National Council on Interpreting in Health Care: Working Papers Series.

Virtual Health Library run by BIREME, the Latin American and Caribbean Health Sciences Information Center, a WHO/PAHO program. Includes a regional health information locator, access to journal articles, and a trilingual English-Portuguese-Spanish dictionary in the form of a health terminology search engine.

Professional Associations

The American Translators Association has chapters nationwide and maintains affliations with many other local groups.

The California Healthcare Interpreting Association has compiled a list not only of health care interpreting associations, but also of other interpreting and translation associations nationwide.

Though Linguist List is not a professional organization, it offers a wealth of information on individual linguists as well as associations of linguists, linguistic research centers, and other topics. This information may be helpful for people looking to link up with linguists or other linguistic resources.

Massachusetts Medical Interpreters Association (MMIA)

Multicultural Association of Medical Interpreters of Central New York (MAMI)

National Council of Interpreters in Health Care (NCIHC)

Society of Medical Interpreters

Related Websites and Organizations

Blogos - News and views on languages and technology

California Pan - Ethnic Health Network's Multicultural Health Web Portal

Cross Cultural Health Care Program

Diversity RX


Federal Government LEP Policy Guidance

Interpreter Training Resources

National Health Law Program

Center for Immigrant Health

news coverage

Media stories can be found in the Media Center.

Interpreter's Training

George Mason University Interpreter Training Program