Usability of technological tools to overcome language barriers in health care: a scoping review protocol

Abstract

Introduction

In many healthcare contexts globally, where the languages of care providers and patients do not match, miscommunication or non-communication can lead to inaccurate diagnoses and subpar treatment outcomes. In order to bridge these language barriers, a range of informal practices are used, such as family members or staff acting as interpreters, ‘receptive multilingualism’ or machine translation. The development and use of technological tools are increasing, but factors such as translation quality for complex health-related texts vary widely between languages. The objective of this scoping review is to (1) identify and describe the technological tools used in direct patient-provider communication to overcome a language barrier in a healthcare setting, (2) identify how the usability of these tools was evaluated and (3) assess the usability of the technological tools.

Methods and analysis

The scoping review will follow the Joanna Briggs Institute methodology. A search strategy using variations of the keywords ‘technological tools’, ‘language barrier’ and ‘healthcare’ will be applied in the following databases and research platforms: PubMed, PsycArticle, Scopus, EBSCOhost, ProQuest and Web of Science. All literature where individuals use a technological tool to overcome a language barrier in a healthcare context will be included and exported into the screening assistant software Rayyan. The search will be limited to articles written in German or English. Two independent reviewers will screen the articles, and all relevant extracted data will be presented in a descriptive summary.

Ethics and dissemination

This scoping review does not require ethical approval, as the study’s methodology consists of collecting data from publicly available sources. The findings will be disseminated through publication in an open-access, peer-reviewed journal and presentations at scientific conferences. The scoping review results will also guide future research in a multinational project investigating multilingualism in providing (mental) healthcare to migrants.

Strengths and limitations of this study.

• The scoping review follows the methodology for scoping reviews developed and established by the Joanna Briggs Institute.

• The search strategy will be comprehensive, encompassing multiple databases and research platforms, including evidence from peer-reviewed journals and grey literature.

• The screening process will be conducted in a blinded fashion by two independent reviewers with the assisting software, Rayyan.

• The review will only include literature published in English and German.

Introduction

Language barriers are common in healthcare settings around the world. For example, in a Dutch hospital, almost 40% of the patients who participated in the study and belonged to an ethnic minority group reported that they had limited communication skills in the dominant language.¹ In South Africa, where there are 12 official national languages, more than 80% of medical consultations take place despite language barriers; only 6% of medical interactions are fully or partially in the patient’s native language.^{2 3} In China, there are asymmetries in terms of health, healthcare and access to healthcare for the different groups of migrants living there.^4–7 About 37% of migrants who participated in a survey and had been living in Germany for 11 years or more reported low German language skills, and 12% of migrant patients in outpatient oncological or psychiatric treatment did not speak enough German for regular consultation.^{8 9}

Language barriers affect access to care, assessment accuracy, diagnosis and the quality of treatment.^10–13 Confusion among patients and healthcare professionals about diagnosis and treatment can lead to reduced treatment adherence, worse outcomes and premature treatment discontinuation.^14–16 Although the problem of language barriers in healthcare is well known, addressing and improving the situation remains largely neglected in research, education and practice. Many countries implicitly or explicitly expect migrants to learn the dominant language.^{17 18}

Several informal practices have emerged in many healthcare contexts around the world, including using family members or staff as interpreters.^19–21 Other practices include using gestures, facial expressions and increased volume or ‘receptive multilingualism’.²² The use of such practices is understandable in the absence of alternatives. However, these approaches can lead to translation errors or the omission of sensitive information.^19–23

The use of qualified interpreters is another approach when service providers and patients do not share a common language.^24–27 However, this resource is unavailable in many countries, for example, because of the non-existent legal framework for its use, missing qualification standards or the lack of payment for interpreters.^{26 27} Qualified interpreters, especially for rare languages, are not widely available.^24–27 Bureaucratic hurdles make it difficult to access human-interpreting resources. Healthcare providers often lack knowledge and may have negative attitudes towards working with qualified interpreters.^{26 27}

Technological tools to overcome language barriers can be a way to provide healthcare despite language barriers, especially when (qualified) interpreters are not available.²⁸ New applications (apps) are constantly being developed and released, and the technological world is constantly changing.²⁹ For example, online dictionaries enable individuals to translate words into different languages. Some applications work with fixed phrases that have been professionally translated beforehand, often in text and audio form.^{28 29} Another example is machine translation, where users can write or speak the sentences and translations are provided instantly by artificial intelligence.^30–32 In the field of machine translation, one application that is freely available is ‘Google Translate’. Regarding the quality of this technological tool, it was found in 2016 that when translating diabetes health information from English into Spanish and Chinese, simpler sentences performed better. The potential for delays in patient care due to incorrect or misunderstood information was noted for more complex sentence structures.³⁰ Another study translated common medical terms and phrases into 26 languages and found some serious errors. Overall, about 58% of the translations were correct. Western European languages were the best translated, with a 74% accuracy rate, followed by Eastern European (62%), Asian (46%) and African languages (45%).³¹ The evaluation of the translation of discharge instructions in emergency departments, published in 2021, found that the basic meaning of the context was correct in about 82% of the letters. However, the linguistic accuracy ranged from 55% (Armenian) to 94% (Spanish), depending on the language. Accordingly, qualitative differences were found between languages, and in a few cases, translation errors led to non-sensical discharge instructions.³²

There are a few translation tools developed specifically for the medical context. The usability and efficiency of an app were tested in the infirmary of a refugee arrival centre in Germany. Patients used the app in one of 13 languages and selected the text modules that applied to them through a systematic query. Seventy-six per cent of users reported that the app was easy to use, and 65% reported that they could communicate their main symptoms.²⁸ The same project group developed and evaluated a smartphone app for emergency medical services, also using fixed text modules and a systematic query approach. Usability was calculated using the System Usability Score, and a median of 67 points was achieved, indicating good usability.³³

A published review collecting data up to 2019 investigated the extent to which the development, acceptability and efficiency of health promotion and language translation apps have been evaluated, with a focus on migrants and language barriers.²⁹ For example, acceptability was measured using satisfaction surveys, participant comments, length of consultation time and app usage data. Some reviewed studies used the System Usability Scale, the Technology Acceptance Model and the Stanford Communication with Physicians Scale.²⁹ Only two of the language-translation apps were evaluated for efficiency, with outcomes focussing on the accuracy of medical information. Translation apps were found to reduce patient anxiety, consultation time and the need for a human interpreter. Limitations in conducting conversations and building a therapeutic relationship between healthcare providers and patients were mentioned as possible negative effects.²⁹ Hospital admission wards, emergency care and refugee arrival centres were the main areas of application and research focus.^{33 34}

There are currently no binding standards for assessing quality criteria and indicators such as usability, user behaviour and translation quality when testing technological tools to overcome language barriers in healthcare.^{29 35} To address this lack of binding standards, the umbrella term usability will be used to map the existing body of evidence.

Usability refers to how effectively and efficiently users—in this context, both providers and patients—can interact with and use technological tools to facilitate communication despite language barriers.³⁶ Therefore, usability is the extent to which an application is easy to learn, intuitive to use and enables users to perform their tasks accurately and efficiently. One of the outcome usability dimensions is learnability, which refers to the ease with which users, including providers and patients, can quickly understand and engage with the application’s interface and features. Efficiency pertains to the app’s users’ speed when performing tasks and interacting with the application. Effectiveness focuses on the app’s fundamental purpose, enabling coherent communication despite language barriers in a healthcare setting. The accuracy of translation and interpretation is assessed. Satisfaction is determined by the users’ perceptions of the application’s aesthetics, ease of use and overall experience. Accessibility refers to the app’s capacity to accommodate users who may have varying technical skills and potential impairments in an inclusive manner.23 28 33 35 36 Surveys, qualitative interviews, user feedback, observational studies and objective performance metrics are among the common tools used to gather evidence.23 28 29 33 35

Due to the rapid advances in technology and research, it is considered beneficial to provide a comprehensive overview of the literature published since 2019 in the form of this scoping review. A preliminary search revealed that studies had been conducted and published that met these review’s inclusion criteria.

The aim of this review is to (1) identify and describe the technological tools used in direct patient-provider communication to overcome a language barrier in a healthcare setting, (2) identify how the usability of these tools is being evaluated and (3) assess these tools in terms of usability.

Review questions

1. What technological tools are available for direct patient–provider communication to overcome language barriers in a healthcare setting?

2. How have the technological tools been evaluated in terms of usability?

3. What is the usability of the technological tools?

Methods and analysis

The research questions will be answered by means of a scoping review; this type of review was chosen because an exploratory approach is more appropriate for less researched topics, and it allows for the inclusion of different types of sources and evidence, as well as determining the extent of existing evidence regardless of quality. This allows the current state of research to be presented and gaps to be identified.^{37 38} The proposed review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews.³⁹ The protocol was registered on Open Science Framework (https://osf.io/xepsq).

Eligibility criteria

Participants

The scoping review will include literature where individuals communicate directly with each other while experiencing language barriers in a healthcare context. Publications will be excluded if the communication barrier is due to other reasons, such as deafness or other physical and mental impairments. Similarly, studies will be excluded if a person (interpreter) is used to overcome the language barrier, as the focus is on direct and immediate communication. Otherwise, no studies will be excluded based on participants’ sex, age or sociodemographic factors.

Concept

Studies that identify and describe technological tools used in direct and immediate patient–provider communication to overcome language barriers by optimally assessing indicators, such as usability, will be included. Studies will be excluded if they present tools or aids that are based only on print material or if the focus of the application is not on direct and immediate communication between individuals (eg, multilingual eMental Health apps).

Context

The context of this scoping review is defined as medical consultations and healthcare settings where people communicate directly and immediately with each other to receive healthcare services. Accordingly, only studies containing information on healthcare aspects will be included.

Types of sources

This scoping review will include all types of sources and, therefore, study designs if they fit the inclusion criteria. This includes randomised controlled trials, non-randomised controlled trials, before and after studies, interrupted time-series studies, analytical observational studies such as prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies. Descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies, will also be taken into account. Additionally, qualitative studies that focus on qualitative data using designs such as phenomenology, grounded theory, qualitative description and action research will be considered. Systematic reviews, if they meet the inclusion criteria, will also be examined. To be eligible for inclusion, studies must be accessible through the databases and research platforms searched in this review. However, any relevant studies discovered during the screening of reference lists from the included sources of evidence will be examined regardless of this criterion. Conference abstracts will be excluded.

Search strategy

The search strategy will aim to identify published, unpublished and grey literature available in online databases and research platforms. Based on the results of a preliminary search (databases: PubMed and PsycArticle), a search strategy was developed using variations of the keywords ‘technological tools’, ‘language barrier’ and ‘healthcare’ in the following databases: PubMed, PsycArticle and Scopus. These databases were chosen because they allow searching for a large number of publications in the biomedical, life sciences and psychosocial fields, as well as in the social sciences and humanities. The research platform EBSCOhost will be used, where specific linguistic, healthcare and psychology databases can be searched. ProQuest Dissertations & Theses and Web of Science will also be used. The search strategy, including all identified keywords and index terms, will be adapted for each database and information source included. The comprehensive search strategy for PubMed is provided (online supplemental file 1). In addition, the references to the included literature will be manually searched for suitable publications that may not have been identified in the databases by the search strategy applied.

The search will be limited to articles written in German or English, aligning with the researchers’ language proficiency. The possibility of excluding relevant studies in other languages, which may introduce language bias, is acknowledged. Studies published since 2019 will be included, as the review by Thonon et al has a broad thematic overlap and already presents findings from the literature up to 2019.²⁹

Study and source of evidence selection

Following the search, all identified citations will be collated and uploaded into the Rayyan screening assistant software and duplicates will be removed. The Rayyan software facilitates the screening of titles and abstracts, which will be assessed against the inclusion criteria by two independent reviewers in a blinded fashion.⁴⁰ The remaining sources will be retrieved in full text and assessed in detail. Reasons for the exclusion of sources of evidence will be recorded and reported in the scoping review. Disagreements that arise between the reviewers at any stage of the selection process will be resolved by discussion or with an additional reviewer. The results of the search and the study inclusion process will be fully reported in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR) flow diagram.³⁸

Data extraction

Two independent reviewers will manually extract data from the included literature using a self-developed extraction form: authors, year, country, type of publication or reference, study design, objective, participants, sample size, concept, context, setting, method of data collection, method of data analysis and key findings relevant to the research questions. A draft data extraction form is provided (see online supplemental file 2). The tool will be tested, modified and revised as necessary during the process of extracting data from each included source of evidence. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved by consensus or with an additional reviewer. Where appropriate, authors of papers will be contacted to request missing or additional data, where required.

Data analysis and presentation

The data will be presented in tabular form, but other formats may be considered once the data have been charted and analysed, if these allow a better presentation of the results. A PRISMA-ScR flowchart and description will be provided to offer an overview of the evidence search and selection process. A table will present the characteristics of the included literature to illustrate information such as authors, study design, objective, participants, concept, context and other key factors relevant to the research questions. Application-specific results, such as the number of languages supported and whether and how usability was measured, will be presented in another table. The results will be summarised in narrative and descriptive form. This synthesis and presentation of findings will describe how they relate to the research questions. Specifically, it will cover the types of tools available, the contexts in which they have been used, the users of these tools and an evaluation of their usability.

The findings of the review will provide an overview of the existing body of studies, identify research gaps and thus provide guidance for future research.

Ethics and dissemination

Ethical approval is not required for this review, as the methodology of the study is to collect data from publicly available sources. The results will be disseminated through publication in an open-access, peer-reviewed journal and through presentations at scientific conferences. The results of the scoping review will also guide future research in a multinational project investigating multilingualism in providing quality mental healthcare.

Patient and public involvement

Due to the nature of the scoping review, there was no patient and/or public involvement.

Ethics statements

Patient consent for publication

Not applicable.