Abstract
Background
Immigrants from Chuuk, a Pacific Island nation in Micronesia, are a growing population of limited-English speakers in Hawai‘i. The purpose of this study was to examine the perspectives of Chuukese patients and their physicians in Honolulu, Hawai‘i on interpreter services.
Methods
An anonymous multiple choice survey was distributed to potential patients through a Chuukese community group and to physicians through the Hawai‘i Residency Programs to examine the following sources of interpreters: Family member or friend, telephone interpreter, or professional in-person interpreter. Statistical significance of cross-tabulated responses was analyzed using Fisher's exact test.
Results
114 surveys from health care providers and 95 surveys from Chuukese community members were analyzed after exclusion criteria. Using a family member or friend was the method most frequently used by physicians (78%) and Chuukese patients (71%). Telephone interpreters were used the least by physicians (6%) and Chuukese patients (2%) and both rated it poorly in terms of comfort and ease of use. Physicians rated professional in-person interpreters as the best method (67%) while Chuukese patients rated using a family member or friend as the best method (61%), especially among those who reported a lower English proficiency (P = .04) and who lived in Hawai‘i for fewer years (P > .01).
Discussion
The preference of Chuukese patients for using a family member or friend as interpreter differs from national standards which promote the use of a professional interpreter. Given the preference of both physicians and Chuukese patients for in-person interpreters over telephone interpreters, there is a need for increased training and hiring of in-person interpreters.
Keywords: Chuukese, Micronesian, translator, medical interpreters, language barrier, telephone interpreter, professional interpreter, cross cultural care
Introduction
The National Standards on Culturally and Linguistically Appropriate Services requires that health care organizations provide patients with limited English proficiency free access to interpreter services at all points of contact in a timely manner. Furthermore, they must assure the competence of translation services, and family and friends should not be used as translators unless requested by the patient. A recent survey of 135 hospitals found that many hospitals are not meeting these requirements, with only 78% able to provide timely language services in the emergency department and 62% using patients' family and friends to translate.1 Outpatient clinics show similar trends, with 70% reporting using patients' family and friends to translate.2 Multiple studies, including both cross sectional surveys and randomized controlled trials, have shown that patient satisfaction, health care provider satisfaction, quality of care, and health outcomes are improved and fewer interpreting errors occur with the use of trained professional interpreters as opposed to ad hoc translators such as family members or friends.3–6 Most of these national studies have examined primarily Spanish speaking patients. Few have looked at languages in which the availability of bilingual staff or professional interpreters is more limited, such as Micronesian languages. Micronesians are a growing population in the United States, with 40% of Micronesians living in Hawai‘i and 41% of that group living within the city of Honolulu. After a 251% increase in the Micronesian population between 1990 and 2000, a 2006 inter-censal estimate showed 14,000 Micronesians in Hawai‘i. A vast majority are from the Federal States of Micronesia, which includes the nation of Chuuk. Eighty percent do not use English as their primary language, and thus may rely on interpreters during their health care encounters.7–9 Due to the limited availability of in-person Micronesian interpreters, telephone interpreters or family/friends are often used. There has been growing interest in training Micronesians as professional interpreters. However previous studies have shown conflicting results in whether patient satisfaction, and clinical outcomes are improved with professional in-person interpreters or telephone interpreters.10–11
The purpose of this study was to assess the availability, utility, accuracy, satisfaction, and cultural appropriateness of different sources of interpreters from the perspectives of both Chuukese patients and their physicians.
Methods
An anonymous multiple-choice survey tool was administered to physicians and Chuukese community members in Honolulu, Hawai‘i to examine the following types of interpreters: family member or friend, professional interpreter via telephone, or in-person professional interpreter. For each of the methods, the survey asked about the user's opinion on the availability, ease of use, accuracy, and cultural appropriateness of the method as well as the user's overall preferred method. Physicians were also asked about any perceived barrier to its use in the healthcare setting.
The following demographic information was collected in the Chuukese community survey: age, gender, years lived in Hawai‘i, and clinic most visited. The following demographic information was collected on the physician surveys: healthcare role (resident or attending physician), department or specialty, age, gender, and clinic.
The survey for physicians was created on SurveyMonkey and distributed to attending physicians and residents via e-mail by program administrators through the Hawai‘i Residency Program. The survey was also distributed via e-mail by the respective medical directors at Kokua Kalihi Valley and Kalihi Palama Health Center, two community health centers in Honolulu who serve a large number of Chuukese patients. Physician participants were offered $5 Starbucks cards as incentives.
The survey for Chuukese community members was translated and back-translated by professionally trained Chuukese interpreters through the University of Hawai‘i and New Nations of Micronesia, a Chuukese community group based in Hawai‘i. In partnership with this community group, the paper surveys were administered by the translators at various community and church events without the presence of health care providers to encourage accurate responses without fear of retaliation. Participants from the Chuukese community were offered single ride bus vouchers as incentives.
Only physician and Chuukese respondents who worked at or visited the largest health centers in Honolulu serving Chuukese patients (Kokua Kalihi Valley, Kalihi Palama, Queen's Medical Center, and Kapi‘olani Medical Center) were included for data analysis. Health care provider respondents who were not physicians or residents were excluded, as well as those who had never used a family member or friend for translation since this widely used method was the baseline for comparisons with other methods. Preliminary analyses examined the frequencies of survey responses. Subsequent analyses compared questions by cross-tabulating responses. Statistical significance was assessed with Fischer's Exact Test. This study was approved by the Hawai‘i Pacific Health Research Institute HPHRI # 2011-008 and determined to be IRB exempt.
Results
Physician Surveys
In all, 127 surveys were collected from health care providers and 114 were analyzed after exclusion criteria. See Table 1 for demographic data and Table 2 and Table 3 for survey response results. Telephone interpreter services are largely available, with only 8% of providers reporting it unavailable, compared to 27% of providers reporting in-person clinic interpreter services unavailable. However, attending physicians and residents report the most frequent method actually used was family member or friend (78%) compared to telephone (6%) or in-person clinic or hospital interpreter (13%). Barriers to using a telephone interpreter included “taking too long” (61%) and “too hard to use” (26%). Barriers to using an in-person clinic interpreter included “taking too long” (33%) and being “too expensive” (10%). Overall attending physicians and residents felt that an in-person clinic interpreter was the best way to talk with Chuukese speaking patients (67%) compared to a telephone interpreter (4%) and family member or friend (22%). Compared to attending physicians, residents were significantly more likely to rate a family member or friend as the best way to talk with patients (37% compared to 12%, P > .01) and as the most frequently used method (96% compared to 66%, P > .01).
Table 1.
Demographics of Survey Respondents
| Frequency | Percentage | |
| Physician Survey Respondents (n=114) | ||
| Healthcare Role | ||
| Physician | 68 | 60% |
| Resident | 46 | 40% |
| Specialty | ||
| Pediatrics | 67 | 61% |
| Internal Medicine | 26 | 24% |
| Ob/Gyn | 12 | 11% |
| Family Practice | 5 | 5% |
| Psychiatry | 4 | 4% |
| Healthcare Facility | ||
| (Reflects multiple choices by some respondents) | ||
| Kapi‘olani Medical Center | 73 | 64% |
| Queens Medical Center | 53 | 46% |
| Kokua Kalihi Valley | 12 | 11% |
| Kalihi Palama Health Center | 4 | 4% |
| Gender | ||
| Female | 62 | 54% |
| Male | 52 | 46% |
| Age | ||
| Less than 50 | 87 | 69% |
| 50 and older | 14 | 11% |
| Chuukese Patient Survey Respondents (n=95) | ||
| Age | ||
| Under 50 | 77 | 81% |
| 50 or older | 16 | 19% |
| Gender | ||
| Female | 73 | 78% |
| Male | 21 | 22% |
| Number of years lived in Hawai‘i | ||
| <1 | 2 | 2% |
| 1–4 | 54 | 59% |
| 5–9 | 29 | 32% |
| 10–14 | 4 | 4% |
| 15 or more | 2 | 2% |
| Healthcare Facility Used (Reflects multiple choices by some respondents) | ||
| Kapi‘olani Medical Center | 42 | 44% |
| Queens Medical Center | 22 | 23% |
| Kalihi Palama Health Center | 16 | 17% |
| Kokua Kalihi Valley | 35 | 37% |
| Reported English proficiency | ||
| Very good | 9 | 10% |
| Good | 17 | 18% |
| A little | 24 | 26% |
| Not good | 44 | 47% |
Table 2.
Survey Responses on Different Interpretation Methods
| Physician responses | Chuukese patient responses | |||||
| Yes | No | Yes | No | |||
| Family member or friend | ||||||
| Accurate and Understandable? | n=114 | 67 (59%) | 47 (41%) | n=67 | 35 (52%) | 32 (48%) |
| Culturally Appropriate or Comfortable Method? | n=114 | 80 (70%) | 34 (30%) | n=68 | 41 (60%) | 27 (40%) |
| Telephone interpreter | ||||||
| Accurate and Understandable? | n=78 | 68 (87%) | 10 (13%) | n=21 | 14 (67%) | 7 (33%) |
| Culturally Appropriate or Comfortable Method? | n=78 | 46 (60%) | 31 (40%) | n=21 | 9 (43%) | 12 (57%) |
| In-person clinic interpreter | ||||||
| Accurate and Understandable? | n=73 | 73 (100%) | 0 (0%) | n=65 | 26 (40%) | 39 (60%) |
| Culturally Appropriate or Comfortable Method? | n=73 | 71 (97%) | 2 (3%) | n=64 | 26 (41%) | 38 (59%) |
Questions are paraphrased. More people had used and were able to rate using a fmaily member or friend compared to other methods. Survey response choices “Yes” and “Mostly” are combined into “Yes”, and “A little” and “No” are combined into “No” in this table.
Table 3.
Physician and Chuukese Patient Responses Comparing Their Most Frequently Used and Most Preferred Interpretation Method
| Survey Questions | Family member or friend | In-person clinic interpreter | Telephone interpreter |
| Which method do you use the most? | |||
| Physician respondents (n=114) | 89 (78%) | 15 (13%) | 7 (6%) |
| Chuukese respondents (n=95) | 65 (71%) | 18 (20%) | 2 (2%) |
| Which method is the best? | |||
| Physicians respondents (n=114) | 25 (22%) | 76 (67%) | 5 (4%) |
| Chuukese respondents (n=95) | 55 (61%) | 26 (29%) | 3 (3%) |
Chuukese Surveys
In all, 111 surveys were collected from the Chuukese community and 95 were analyzed after exclusion criteria. See Table 1 for demographic data and Table 2 and Table 3 for survey response results. Seventy-five percent reported needing translation assistance with their doctor. Thirty-one percent reported acting as a translator for a family member or friend. Only 21% reported using a telephone translator and 66% reported using an in-person clinic translator. The most frequently used method was family member or friend (71%) compared to in-person interpreter (20%) and telephone interpreter (2%). The preferred method was family or friend (61%), followed by in-person interpreter (29%), and telephone (3%). People who reported lower English proficiency (rated as “a little” and “not good” as compared to “good” and “very good”) were more likely to report using a family member as the preferred method (72% versus 44% of respondents who reported higher English proficiency, P > .01). People who reported lower English proficiency were also more likely to report understanding their doctor only “a little” or “not much” (67% versus 25%, P > .01) and feel less comfortable (67% versus 25%, P = .01) with an in-person clinic interpreter. People who lived in Hawai‘i for less than 5 years were more likely to report using a family member as the preferred method than those who had lived in Hawai‘i longer (69% versus 47%, P > .01).
Discussion
Despite good reported availability of telephone interpreter services, physicians, residents, and Chuukese patients do not rate them favorably in terms of comfort and ease of use and do not use them frequently. Both physicians/residents and Chuukese patients report using a family member or friend as the most frequently used translation method. While overall a majority of both attending physicians and residents rate in-person interpreters as the preferred method, the proportion of residents who reported using a family member or friend as the preferred method was greater than that among attending physicians. In contrast, a majority of Chuukese respondents report using a family member or friend as the preferred interpreters, especially those with lower self-reported English proficiency and who have lived in Hawai‘i for fewer years.
Physicians have been encouraged to use professional interpreters with limited English speaking patients to protect patient confidentiality and ensure accurate and transparent communication. Much of the literature on cross cultural care has been based on Hispanic populations and demonstrates a preference for professional interpreters over family and friends. The attending physicians' and residents' results for the perceived best method largely reflect these findings, and may, in fact, be an attempt to try to give the “right” answer as taught in contemporary medical education. Despite this preference, most physicians still report using a family member or friend as the most utilized method, which likely reflects the reported lack of availability of the best method in real practice. However, the preferences of the Chuukese patients in our sample appear to be very different. The reason for this was not addressed in this study. Chuukese patients may feel more comfortable talking about their personal medical issues with a close family member or friend compared to a stranger. One professionally trained Chuukese interpreter noted that Chuukese patients may not trust strangers to discuss their medical problems with their doctor. Anecdotally, some community providers noted that there may also be multiple regional differences in Chuukese dialects that make it difficult to utilize professional interpreter services broadly. The difference in opinion between physicians and Chuukese patients challenges our current national standards in medicine, which have traditionally advised against using family members or friends as interpreters. They highlight how culturally sensitive health care should be tailored to the preferences of the individual cultural group or perhaps the individual patient.
Limitations of this study include the discretely different physician and patient populations. We surveyed Chuukese community members outside of the medical establishment in partnership with a Chuukese community group to encourage honest responses that might be withheld in the presence of health care providers. Therefore, our participants do not necessarily represent the specific patients with whom the surveyed physician population interacts. However, we did limit our statistical analysis and exclusion criteria to the four largest identified health care providers among the surveyed Chuukese community to provide the best possible comparison. We were unable to compare responses by health care facility since several physician and Chuukese patient respondents identified with multiple facilities.
Despite these limitations, this study is the first to examine the use of sources of interpreters in a Micronesian population, which is a growing population of non-English speakers in Hawai‘i and is increasingly accessing the health care system. Given the preference of both physicians and Chuukese community members for in-person interpreters over telephone interpreters, there is a need for the training and hiring of in-person interpreters at medical facilities. There may also be a need for educational outreach to the Chuukese community to teach about the potential benefits of using a professionally trained interpreter as opposed to a friend or family member for medical translation which may help increase comfort and utilization of this method among Chuukese patients. Our results show that many physicians from multiple hospital centers do not feel that in-person interpreters are readily available at their facilities. Future studies are needed to help understand the discrepancy between Chuukese patients and their physicians in preference for in-person professional interpreters versus a family member or friend as interpreter and to determine the accuracy of Chuukese translation by each of the available methods.
Acknowledgements
We gratefully acknowledge the community and study support from Dr. Brenda Nishikawa from Kapi‘olani Medical Center and Barbara Tom from Nations of Micronesia. This study received funding support from a resident research grant from the Pacific Medical Administrative Group and biostatistical support by grants from the National Center for Research Resources (U54RR026136) and the National Institute on Minority Health and Health Disparities (U54MD007584).
Conflict of Interest
None of the authors identify any conflict of interest.
References
- 1.Diamond LC, Wilson-Stronks A, Jacobs EA. Do hospitals measure up to the national culturally and linguistically appropriate services standards? Med Care. 2010;48(12):1080–1087. doi: 10.1097/MLR.0b013e3181f380bc. [DOI] [PubMed] [Google Scholar]
- 2.Kuo DZ, et al. Pediatricians' use of language services for families with limited English proficiency. Pediatrics. 2007;119(4):e920–e927. doi: 10.1542/peds.2006-1508. [DOI] [PubMed] [Google Scholar]
- 3.Karliner LS, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. doi: 10.1111/j.1475-6773.2006.00629.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255–299. doi: 10.1177/1077558705275416. [DOI] [PubMed] [Google Scholar]
- 5.Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: a clinical review. J Health Care Poor Underserved. 2008;19(2):352–362. doi: 10.1353/hpu.0.0019. [DOI] [PubMed] [Google Scholar]
- 6.Flores G, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111(1):6–14. doi: 10.1542/peds.111.1.6. [DOI] [PubMed] [Google Scholar]
- 7.Evensen S. Needs Assessment for Micronesian Health Care in Hawaii. 2009. [cited 2011 January 3 2011]; Available from: http://www.prel.org/media/133841/nnlm%20micronesian%20health%20report.pdf.
- 8.Huskins D. Census 2000 Demographics of Micronesians in the United States, U.o.A.I.f.H.a.S. Policy, Editor 2000: Akron
- 9.Pobutsky A, et al. Micronesian Migrants in Hawaii: Health Issues and Culturally appropriate, community-based solutions. California Journal of Health Promotion. 2005;3(4):59–72. [Google Scholar]
- 10.Crossman KL, et al. Interpreters: telephonic, in-person interpretation and bilingual providers. Pediatrics. 2010;125(3):e631–e638. doi: 10.1542/peds.2009-0769. [DOI] [PubMed] [Google Scholar]
- 11.Garcia EA, et al. A comparison of the influence of hospital-trained, ad hoc, and telephone interpreters on perceived satisfaction of limited English-proficient parents presenting to a pediatric emergency department. Pediatr Emerg Care. 2004;20(6):373–378. doi: 10.1097/01.pec.0000133611.42699.08. [DOI] [PubMed] [Google Scholar]