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Regarding health outcomes, populations that are ethnically, culturally, and linguistically diverse are considered to be especially vulnerable. Communication between dental healthcare providers and limited English proficient (LEP) patients is often compromised by language barriers, and this situation is further exacerbated by limited access to language assistance services in verbal and nonverbal communication. Cultural barriers, including differences in the traditional oral health practices and beliefs of patients, can create additional complications, such as refusal of treatment plans and inadequate follow-up after treatment. For LEP patients, it is especially important that patient education, explanations of treatment plans, and informed consent processes are linguistically appropriate. The consequences of poor communication in healthcare are far-reaching, ranging from compromised access to care to poor health outcomes. This article provides resources to help dental practices develop systems for navigating appointments involving linguistically diverse patients.
Population Diversity and Healthcare Access
The population of the United States is becoming increasingly diverse.1 According to the most recent data from the US Census Bureau, 21.7% of the US population speaks a language other than English at home, and of those who speak English, 8.2% do not do so very well.2 Research has shown that LEP individuals are at risk of experiencing reduced access to health services as a result of their inability to understand health-related information and are at risk of experiencing language barriers that can negatively affect their ability to communicate with providers and negatively impact their overall health outcomes.3-7
The ethnically diverse population of the United States includes LEP individuals who are both native born and immigrants. Immigrants arrive in this country under a wide variety of circumstances. Although some come for reasons related to work or family, others are refugees who are fleeing war or persecution. The World Health Organization notes that there are a number of barriers that limit the access to health services for refugees and migrants, including inadequate access to mainstream health services, institutional discrimination, poor housing and working conditions, poverty, previous trauma, cultural barriers, low health literacy, and language barriers.8
Regulatory Requirements for Language Services
According to the US Department of Health and Human Services (HHS) Office for Civil Rights, "Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may be limited English proficient, or ‘LEP,' and may be eligible to receive language assistance with respect to a particular type of service, benefit, or encounter."9 Title VI of the Civil Rights Act of 1964 protects the right of LEP patients to receive equal access to healthcare and mandates that all healthcare entities that receive federal funds provide language assistance free of charge to all who need it.3,10 Covered entities may include hospitals, nursing homes, universities, managed care programs, and Head Start programs as well as state, county, and local healthcare organizations and other entities that receive Federal funding. This also includes the provision of translation and interpretation services in dental settings that receive federal funds.11 Although the provision of language services is legally mandated for institutions that receive federal funding,11,12 language assistance is not always provided at such facilites.13 Healthcare providers cite financial barriers, organizational barriers in identifying LEP patients, and the inability to access professional interpreters as reasons for failures in providing language assistance.13-15 Nonetheless, the utilization of translators and interpreters in healthcare is a critical component of linguistically appropriate communication between LEP patients and providers.
Language Assistance Services in Healthcare
There are major differences between translators and interpreters. Translators work in one direction, converting the written word from one language to another, whereas interpreters work bidirectionally, converting spoken language as it is uttered in real time.16 The selection of competent translators and interpreters, as well as an appropriate mode of interpretation, is crucial for adequate communication between healthcare providers and LEP patients.
The Use of Translators
According to the American Translators Association, anyone in the United States who is competent in both English and in a foreign language can translate documents and certify their own translations.17 Besides being exemplary writers in both languages, translators should also be skilled at conveying the message of the text accurately, even if there is no direct translation available for a word in the target language. In such cases, the translator should make the provider aware so that both parties can work together to develop descriptions of untranslatable words, such as medical terms, for future use. Guidance from the US Department of Justice's Civil Rights Division recommends that the translation of written documents should be arranged for the most common languages encountered or any LEP patient population that comprises 5% or more of the total patient population.18 The more vital the document, the higher the skill of the translator required. Table 1 provides a list of vital and nonvital documents.9 When a document is translated, it should be done so at a level of literacy that the patient can understand.
The Use of Interpreters
Interpreters, on the other hand, require different skills and qualifications. HHS notes that competency to interpret spoken language in healthcare communications does not necessarily mean formal certification as an interpreter; however, certification can be helpful. In the absence of certification, providers can take certain measures to assure that foreign language interpreters are competent in their ability to interpret fluently and accurately between the source language and target language while accounting for regionalism, maintain confidentiality and partiality, understand technical terminology, and adhere to the role of interpreter while not deviating to other roles, such that of an advisor.9,19 Relatedly, American Sign Language interpreters who provide language assistance to individuals who are deaf or hard of hearing must be certified and are obligated to obtain continuing education credits in order to maintain the certification.20
Practices that receive Federal financial assistance must provide meaningful access to language assistance free of charge and are prohibited from asking patients to provide their own interpreters. However, if patients insist on using a family member as an interpreter instead of an interpreter provided by the practice, the practice should honor their wishes but note this preference in their charts. Patients should be informed of the disadvantages of using family members, especially minors, as interpreters. Issues related to using family members as interpreters include lack of competency, breaches in confidentiality, and potential conflicts of interest. For example, if an LEP woman who was suspected of experiencing domestic abuse presented for treatment with her husband, it would be inappropriate to use the husband as her interpreter.9
Some providers turn to online platforms, such as Google Translate, for interpretation. Although this method may be acceptable in emergency situations, it is not sufficiently accurate or consistent for regular use.21 In circumstances in which the cost of interpretation services is a barrier, cost reduction practices such as the use of telephonic interpretation services, the training of bilingual employees as interpreters and translators, and the use of qualified community volunteers are acceptable.9,19Table 2 lists various types of interpreters that can be utilized in healthcare situations.9 Table 3 provides guidelines that should be followed when working with interpreters during procedures.19,22
As the population in the United States grows increasingly diverse,23 more and more healthcare providers report encountering LEP patients in their practices and cite various strategies for addressing the language needs of these patients, including the use of professional and ad hoc interpreters.24 When LEP patients present at dental practices, oral health professionals should be prepared to employ such strategies. This requires becoming familiar with the various ethnic populations that reside in their communities and developing a plan.
Developing a Language Assistance Plan
To ensure inclusivity and equality in care delivery, organizational systems should be in place that help practices identify and provide language assistance to patients who communicate in languages other than English. Dental practices should develop a language assistance plan that includes strategies for identifying patients who need language assistance, the language assistance methods that will be used, policies for staff training, and a system for the provision of notices to LEP patients. In addition to assisting in practice management, the plan can be used as evidence of compliance with Federal mandates. The extent of language resources available for any given language should be based on the total number of patients who speak it and the frequency at which they utilize services. In addition, a system should be in place that alerts the provider of each patient's language preference.9 This data can be collected by inquiring about patients' language preferences during the intake process through a questionnaire, and/or by displaying signage prompts at the reception desk in various languages, and noting the responses in patient charts. Various resources such as "I speak" cards can be downloaded at LEP.gov.
Language assistance plans should be monitored and updated on an ongoing basis. During reviews, practices may want to consider any changes that have occurred in:
• the current LEP populations in the service area;
• the frequency of encounters with LEP language groups;
• the nature and importance of specific activities to LEP patients;
• the availability of resources, including technological advances, sources of additional resources, and the costs involved;
• the existing needs of LEP patients;
• the staff's knowledge and understanding of the language assistance plan and how to implement it; and
• the availability or viability of identified sources for assistance.9
Conclusion
With the changing demographics of the US population comes the need for linguistically and culturally appropriate healthcare. Dental practices should make it their responsibility to demonstrate inclusivity and promote equality when treating LEP patients. This can be accomplished by considering the cultural background of patients and establishing an organizational language assistance plan. It is important that internal systems are employed to help increase awareness of the language and cultural needs of the patients they serve, bridge the communication gap between patients and providers, and help remove linguistic and cultural barriers to care. Although the Federal government's mandate to provide free language assistance to LEP patients only applies to healthcare entities that receive federal funds, in order to improve access to and deliver the highest quality care, all dental practices should strive to ensure the linguistic and cultural appropriateness of their patient communications.
Queries regarding this course may be submitted to authorqueries@conexiant.com
About the Author
Romana Muller, RDH, MSDH, EdD, is an associate professor at the Missouri School of Dentistry & Oral Health at A.T. Still University in Kirksville, Missouri.
References
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