Utilization of Foreign Language Interpreters A National Survey of SpeechLanguage Pathologists

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Utilization of Foreign Language InterpretersA
National Survey of Speech-Language Pathologists

• Lori Ann Kostich M.S., CFY-SLP
• Southern Connecticut State University
• Deborah Weiss Ph.D., CCC-SLP
• Southern Connecticut State University

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Introduction
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Why Interpreters are Crucial

• 47 million people (18) speak language other than
  English at home
• Language barrier
• Limited number of bilingual SLPs
• Monolingual SLPs must treat with assistance of
  interpreter

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Some Drawbacks

• Fewer comments between physician and patients
  (Rividenerya, Elderkin-Thompson, Silver and
  Waitzkin, 2000)
• More difficult to elicit symptoms (Karliner,
  Eliseo, Perez-Stable and Gildengorin, 2004)
• Physician may not receive adequate input from the
  patient (Elderkin-Thompson, Silver and Waitzkin,
  2001)
• Patients lose opportunity to be involved in care
  and ask questions (Baker, Parker, Williams,
  Coates and Pitkin, 1996)
• Slower, awkward style of communication (Haffner,
  1992)
• Individual style of interpreter (Preloran,
  Browner and Liebner, 2005)

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Types of Interpreters, Considerations and Levels
of Success
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Many Types Utilized

• Highly trained
• Professional in-person
• Professional via telephone connection
• Bilingual SLPs or graduate students
• SLP Assistants
• Ad hoc
• Family and friends
• Community members
• Bilingual staff or individuals from other
  professions

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Professional Interpreters Yield Positive Outcomes

• Garcia, Roy, Okada, Perkins and Wiebe (2004)
• Fluent in both Spanish and English
• Received training in medical Spanish and
  interpretation techniques
• Resulted in higher patient satisfaction with
  doctors and nurses.
• Hornberger, et al. (1996)
• Utilized professional interpreters
• Additional 15 hours of training.
• 10 percent increase in physician utterances
• 12 percent fewer inaccuracies in interpretation

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Professionals Not Always Available

• Due to
• Time constraints
• Limited resources
• Unusual language
• Cost
• (Hornberger, Itakura and Wilson, 1997).
• Thus, interpretation services may be drawn from
  other sources

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Telephone Interpretation Services

• Three-way speaker phone or passing handset back
  and forth
• Available 24 hours, 7 days a week (Leman, 1997)
• Only half of surveyed patients (53.3) were
  satisfied (Kuo and Fagan, 1999)
• Patients as satisfied with care as those seeing
  bilingual healthcare providers face-to-face (Lee,
  Batal, Maselli, and Kutner, 2002)
• High cost (Hornberger et al., 1997)

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Bilingual Faculty/Staff Members as Interpreters

• Elderkin-Thompson et al. (2001) reported use of
  full-time interpreter and several staff nurses
• All had conversational proficiency in medical
  Spanish, but no formal training in interpretation
• 50 of encounters had serious miscommunications
• Bilingual status alone does not guarantee
• sufficient language proficiency
• knowledge of technical terminology
• necessary clinical skills (Hornberger et al.,
  1997).

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Family Members or Friends of Patient as
Interpreters.

• May be preferred by clients
• Kuo and Fagan (1999) reported greater patient
  than physician satisfaction with use of family or
  friends
• Family members can serve adequately as
  interpreters (Hornberger et al., 1997, Leman,
  1997)
• Teenage children may interpret effectively
• (Fadiman, 1997 Green, Free, Bhavnani, and
  Newman, 2005)
• With appropriate training, family can be
  successful
• Roberts (2001)

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Considerations when Utilizing Family and Friends

• Emotion patients role within family (Haffner,
  1992)
• Answer clinical questions without asking patient
  (Marcos, 1979)
• Lack objectivity (Langdon and Cheng, 2002)
• Embarrassment (Kayser, 1995)
• Young children may not be successful as
  interpreters (Flores et al., 2003 Haffner, 1992
  Vasquez and Javier, 1991)
• Interpreter stress decline in ability to speak
  English (Haffner, 1992)

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Interpreter Error

• All interpreters, including professionals, make
  errors
• Flores et al., (2003)
• 31 errors of interpretation per session, some of
  clinical consequence with serious medical
  ramifications.
• errors by ad hoc interpreters more likely to have
  clinical consequence.
• Omissions and distortions due to lack of
  interpreter knowledge (Ebden, Bhatt, Carey and
  Harrison, 1988 Flores et al., 2003 Marcos,
  1979)
• Ebden et al. (1998) - error rates of 23 to 52
  percent
• In psychiatric practice, family members did not
  accurately report what the patient said (Marcos,
  1979).

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SLP Responsibilities Maximizing Success
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ASHA 2004 Position Paper Acceptable
Interpreters

• Bilingual SLPs
• Professional interpreters
• Bilingual professionals other than SLPs
• Family and friends of the client
• All should have native or near native proficiency
  in both languages

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Responsibilities of SLP

• Interpreter Skills and Knowledge (ASHA, 2004)
• Interview techniques
• Confidentiality considerations
• Technical terminology
• Objectives of intervention
• Sensitivity toward culture and speech community
• Tone of intervention, diagnosis, recommendations,
  outcomes follow-up care (Langdon, 2002 ASHA
  2004)
• Without training, interpreter might
  unintentionally change results without
  monolingual SLP awareness (Roberts, 2001)

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Briefing, Interaction, Debriefing (BID) Langdon
and Cheng (2002)

• Briefing - clinician and interpreter meet before
  session to discuss intervention goals make
  interpretation decisions
• Interaction - SLP interpreter work together
  with patient
• Debriefing - clinician interpreter review
  outcomes of session make follow-up plans

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Survey
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Goals

• Obtain information on
• Types of interpreters
• Settings
• Client demographics
• SLP opinions

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Design

• Utilized research and anecdotal information from
• medical profession
• social work
• speech-language pathology
• 45 closed- and open-ended questions
• SurveyMonkey, online survey instrument

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Targeted Participants

• SLPs with current ASHA certification from ASHA
  database
• U.S. cities chosen from Census Bureau tables
• at least 10 of population self-identified as
  speaking language other than English at home
• Target size 382 participants (Creative Research
  Systems, 2003)

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Data Collection

• First mailing
• 2,000 invitation letters sent via U.S. Post
• letter link to survey site provided
• 82 survey responses (4.2)
• Second mailing
• 4,920 invitations sent electronically via email
• consent letter direct link to electronic survey
  
• 563 additional responses (11.4)

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Participants

• Total respondents 645 SLPs
• 174 eliminated (incomplete)
• Total participants 471
• 216 - educational setting
• 214 - medical setting
• 41 - B-3, home care miscellaneous

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Results
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Languages and Dialects Encountered by SLPs (88)

• Albanian, American Sign Language, Amharic,
  Amish, Apache, Arabic,
• Armenian, Assyrian, Azeri, Bengali, Bosnian,
  Caldean, Cantonese, Cambodian
• (unspecified), Cherokee, Chinese (unspecified),
  Creole, Croatian, Czech, Degalo,
• Egyptian, Eritrean, Ethiopian, Farsi, Filipino,
  French, Fukinese, Gambian, German,
• Gilbertese, Greek, Gujarati, Haitian, Hebrew,
  Hindi, Hmong, Hungarian, Ibanog,
• Igbo, Ilocano, Indonesian, Iocian, Italian,
  Japanese, Keres, Kharen, Kmer, Korean,
• Kurdish, Laotian, Lithuanian, Malayalam,
  Mandarin, Marshallese, Micronesian,
• Mongolian, Navajo, Nigerian, Pakistani, Persian,
  Polish, Polynesian, Portuguese,
• Punjabi, Romanian, Russian, Samoan, Serbian,
  Sicilian, Sindil, Spanish, Somali,
• Swahili, Swedish, Tagalog, Tahono Oodham, Thai,
  Tamil, Toishanese, Tongan,
• Tui, Turkish, Vietnamese, Ukranian, Urdu,
  Visayen, Yiddish, Zuni

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Bilingual SLPs

• 66 respondents
• 53 (80) reported they required interpreters
• Bilingual SLPs alone will not solve the problem!

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Distribution of Clients Requiring Interpreters
by Age Group

• All age groups required interpreters
• Greatest need for ages 5-10, 3-4 and 55 years and
  up

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Type of Intervention (Assessment, Treatment)
Requiring Interpreter

• Used more often for assessment than treatment
• Used most often for treatment and assessment of
  receptive and expressive language
• Moderate use for many intervention types
• Less frequent use for voice, APD, dementia,
  fluency

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Frequency of Treatment in English after Bilingual
Assessment (by work setting)

• Educational setting 70 reported treatment in
  English frequently or very frequently vs. 16
  in Medical setting

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Utilization of Interpreters

• Frequency
• 40 - lt once a month
• 29 - 1-3 times a month
• 84 said accessibility varied depending on
  language
• 10 utilized children under 14

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Interpreter Type (IT) Utilized Most Frequently by
SLPs

• All Participants Medical Educational
• HT 44 HT 47 HT 40
• AH 56 AH 53 AH 60

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Research Question 1 Interpreter Type

• Will use of highly trained (HT) vs. ad hoc (AH)
  interpreters result in more positive Clinician
  Perception of Therapy Outcome (CPTO)?

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Results Question 1- Interpreter Type
CPTO avg. of 4 questions (Likert 1-5, never
very frequently)

• T test - plt.0001 (mean difference.270,
  t4.404, df439)
• Therapists who primarily utilize HT interpreters
  have a more positive perception of therapy
  outcome than therapists who primarily utilize AH
  interpreters.

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Time

• Time Needed
• Is additional time needed to assess an LEP
  client? 85 - frequently - very frequently
• Is additional time needed to treat an LEP client?
  48 - frequently - very frequently
• Time Available
• I have time available prior to the intervention
  to review protocol 2.72 (almost never
  sometimes)
• I have time available after the intervention to
  review client performance 3.02 (sometimes)
• TT Total Time calculated for each participant
  as average of 2 Time Available questions above

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Responsibilities - Review of Five ASHA Components

• Group results for 5 ASHA-R components (Likert
  1-5, never to very freqently)
• How often are you able to review/discuss the
  following?
• Cultural norms 3.45
• Effective interview techniques 3.82
• Client confidentiality 4.11
• Technical terms 3.53
• Object of intervention 4.29
• Each participant received ASHA-R score, avg. of 5
  questions

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Research Question 2 Time Available

• Will SLPs who report more Total Time available
  (TT) also report more frequent review of
  ASHA-recommended interpreter competencies
  (ASHA-R)?

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Results Question 2 Time Available

• Pearson correlation highly significant,
  moderately positive correlation of .436 was found
  (n408, z9.406, p.0001, r 2.19)
• Indicates positive relationship between amount of
  time available prior to and after intervention
  (TT) and frequency of review of ASHA-recommended
  interpreter competencies (ASHA-R)

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Research Question 3SLP Responsibilities

• Will more frequent review of ASHA-R with the
  interpreter correlate with higher SLP
  satisfaction level with a) diagnosis accuracy and
  b) treatment efficacy ?

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Results Question 3 SLP Responsibilities

• When assessing a bilingual/LEP client through an
  interpreter, I am as confident in my diagnosis as
  I am with a monolingual client.
• Pearson correlation - significant weak positive
  correlation of .271 (n432, z5.761, plt.0001,
  r2.074)
• When working with an interpreter, I am satisfied
  the treatment is effective.
• Pearson correlation - significant weak positive
  correlation of .364 (n462, z7.913, plt.0001,
  r2.133)
• These results suggest a weak positive
  relationship between the training given to the
  interpreter and
• 1) confidence in the diagnosis
• 2) satisfaction with efficacy of the treatment

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Source of SLP Education Regarding Utilization of
Interpreters

• The largest group of respondents indicated they
  received no training on how to utilize
  interpreters at all.

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Helpful Strategies

• Explain goals of intervention and treatment
  techniques 42 (13.02)
• Speak with interpreter before and after session
  32 (10.16)
• Work with an interpreter multiple times/build
  rapport 32 (10.16)
• Explain the need for accuracy 21 (6.67)
• Instruct the interpreter about appropriate levels
  of cueing and not helping the client
  21(6.67)

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What to Avoid

• Utilizing friends and family as interpreters 32
  (12.40)
• Not defining role of interpreter within
• the intervention 26 (10.08)
• Telephone interpretation systems 13 (5.04)
• Utilizing interpreter with insufficient
• language skills 13 (5.04)
• Trying to explain complex linguistic
• concepts and terms through an interpreter 8
  (3.1)

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Implications for Treatment

• Bilingual/LEP population in the U.S. is growing
  every year
• SLPs need to be familiar with protocols on how to
  work with interpreters
• Graduate programs need to become involved

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Future Research Topics

• Concept of exact interpretation - when can
  interpreter expand on comments without affecting
  outcome?
• Interpreter utilization for bilingual clients
  with aphasia
• Utilization of telephone interpretation services
  for patients with aphasia, paralysis or cognitive
  impairment?
• Continued examination of interpreter availability
  and time constraints faced by SLP and interpreter

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Thank-you!!!

• Contact information
• Deborah Weiss weissd1_at_southernct.edu
• Lori Kostich kostichl1_at_southernct.edu