Promoting quality care in cancer patients with Limited English Proficiency: Perspectives of medical interpreters

Background

Individuals with limited English Fluency (LEP) are a growing population [1]. LEP patients are at high risk for lower quality care, including higher rates of misdiagnoses, medical errors, and serious adverse events [2–4]. Language barriers and underuse of medical interpreters have been widely identified as obstacles to equitable and quality care [2,4], however the rate of professional interpreter use remains unknown. Further, no known study has explored patients’ reasons for refusing interpreter assistance; rather, existing studies have largely focused on physician and parental barriers [3].

LEP patients diagnosed with cancer may be particularly susceptible to adverse outcomes due to communication barriers. Conversations in cancer care often involve complex, confusing and emotionally-laden discussions. In fact, English proficient patients have been shown to have difficulty understanding cancer-related discussions yet are reluctant to ask questions [5]. In effect, poor communication in cancer care may exacerbate patient’s feelings of helplessness and distrust, which may manifest in treatment nonadherence and care dissatisfaction.

Although language barriers have been shown to impact care delivery among LEP populations, little is known about additional factors that may influence the provision of quality care for LEP cancer patients, particularly from the perspective of medical interpreters. Medical interpreters are trained specialists who bridge communication between a patient and their provider. Given their position as medical liaison and cultural broker, interpreters offer a unique outlook of patient experiences that can inform and equip cancer centers with tools to manage the complexities of a linguistically and culturally diverse medical population. Given their distinct position, a number of studies led by Hsieh and colleagues have qualitatively explored interpreters’ perspectives by tapping into their personal challenges and experiences with navigating their role as cultural advocate and medical conduit, particularly as it relates to care delivery [6,7]. However, this is one of the first studies to specifically explore professional interpreters’ perceptions of the potential mechanisms underlying disparities in the care of LEP cancer patients. Moreover, this is among the first studies to solicit interpreters’ recommendations for improving cancer care for LEP patients. As such, this study aims to understand interpreters’ perceptions of factors that impact the quality of cancer care receipt. Secondary aims include exploring interpreters’ recommendations for improving overall cancer care delivery for LEP patients.

Methods

Design and Participants

This qualitative study was part of a larger study which developed and evaluated the effects of a mind-body program, Project CARE (Coping and Enhancing Resiliency), for professional medical interpreters working at three Boston-based hospitals serving a diverse community of cancer patients [8]. It was approved by the MGH/Partners HealthCare Institutional Review Board.

In brief, interested interpreters who worked >20 hours per week at one of the participating hospitals and who had experience working in oncology departments were screened, consented, and scheduled to partake in one of five focus groups. After the group, participants completed 30-minute individual interviews using a semi-structured interview guide that elicited interpreters’ perceptions of factors that reduce LEP patients’ quality of care and strategies to enhance patient satisfaction and quality care specifically in the cancer care context.

Data Analysis

Audiorecordings were transcribed and entered into NVivo10. Two study staff (GKP and MSY) reviewed each transcript to identify themes and develop a coding framework using a framework approach, independently coding all data. Coders met on a regular basis to compare coding schemes. Discrepancies were resolved with comparisons to raw data and through discussions with the PI. A coding comparison query showed acceptable level of coding reliability (Kappa=.91).

Results

Approximately 29 interpreters participated in the study. A majority were female (69%), 30.8% were White, and 53.8% were Hispanic. About half had more than 10 years of interpreting experience, and all interpreted for an average of 6 cancer patient encounters daily.

Interpreter Perspectives of Factors that Compromise LEP Patient Quality of Cancer Care

Three themes emerged related to interpreters’ perceptions of factors that interfere with the provision of quality cancer care for LEP patients: 1) system-level factors; 2) underutilization of trained interpreters; and 3) gaps in patient understanding and interactions with the U.S. medical system. Following are a summary of the major themes with corresponding quotes listed in Table 1.

Table 1.

Interpreter Perspectives of Factors that Compromise LEP Patient Quality of Cancer Care

Theme 1: System-Level Challenges to Care Access

“I just had an interpretation with a woman that is going to have surgery next month. The doctor gave her information about a herniated disk in English because they didn’t have it in Portuguese. The patient needs to find somebody that reads English. I can’t sit in the room and translate everything because there might be other patients waiting…”

Theme 2: Underutilization of Trained Interpreters

Patient-specific Limited knowledge of interpreter services “Sometimes they think that they have to pay extra for it.” “They don’t want an interpreter because they think if they’re going to use the interpreter then the family member cannot go into the room…” Cultural differences/expectations “You know, men in my country…We consider they are the strongest person in the community. I’m a female interpreter. In my country, I’m the weakest and now I’m helping you to communicate…” Fear of appearing incompetent “They don’t like you to think they are stupid or not smart enough or maybe you’ll consider them ignorant and they don’t know the language…they feel badly because they are not speaking the language and they feel like they are ignorant.” Privacy concerns “Some patients own businesses in Chinatown and they know the community is small. They don’t want additional people to know…” Family desire to interpret/withhold information “The family says, ‘I speak English and I’m in charge of my mother’s health. I’m her proxy.’ But the patient wants to talk too. We cannot forget that. There is a lot of resistance from the families.” Provider-specific Provider efforts to save time/perceived language mastery “Usually when I’m refused, I feel it’s more in the grounds of saving time. Sometimes I have arrived to an encounter that has already started…the provider is trying to save time and thinks that they are doing well enough without an interpreter and that it will take longer with the interpreter in the room. “I’ve been called before to the clinic, and when I get there I see the patient coming out. I say, ‘Are you done?’ And he said, ‘yes.’ Then I ask, ‘did you understand?’ And the patient tells me, ‘not really because he used the translation in Google.’”

Theme 3: Patient Interaction with the US Medical System

“It’s really hard for them to keep track of things. We’ll have a telephone call where they’ll say ‘I need to call so and so…’ You say, ‘Well, what’s your medical record number? What is the reason that you are here?’ and [they say] ‘Oh. I don’t know. Somebody asked me to come.’” I think they they’re a little embarrassed to ask questions. They always think they are asking too many questions, or they’re bothering the staff by asking questions.” “…the amount of information is so difficult that they don’t even understand what’s going on because it’s so difficult for them to understand the medical issue. It’s hard for them to ask the right questions because they are not understanding…”

System-level challenges

System-wide limitations in access to care, including limited access to language-specific informational resources (e.g., discharge paperwork or treatment instructions), insurance-related barriers to supportive care (e.g., visiting nurses or hospice care) or medical treatment, longer wait times and shorter medical encounters due to staff shortages were commonly identified sources believed to impact the quality of cancer care LEP patients received.

Patient and provider barriers to the use of trained interpreters

Underutilization of professional interpretation services was unanimously introduced as a principal factor impacting the provision of quality patient care. Specifically, participants observed that patients who procured the help of trained interpreters were more satisfied and comfortable with their care, were more apt to express their concerns and to ask questions, and were more likely to know how to access patient advocacy when needed. Yet, participants acknowledged that patients did not effectively access professional interpreter services. When prompted for reasons for underuse, participants discussed a blending of patient and provider themes: a) patient-level factors, including lack of knowledge regarding free interpreter services, culturally-laden expectations, privacy concerns, and familial barriers; and b) provider-specific factors, including a desire to save time and perceived language mastery.

Patient understanding of and interactions with the medical system

Generally, interpreters found that patients struggled with understanding and engaging with the U.S. medical system. Interpreters noticed patients were unaware of the emphasis placed on patient care involvement in decisions about prescriptions, tests or treatments. They observed patients did not comprehend the differences across specialties and practices. In conjunction with communication difficulties, this often resulted in patients “bouncing” from physician to physician prior to connecting with the appropriate provider. In addition, the interpreters felt that patients had difficulty fully understanding information exchanged during medical encounters, especially when it was replete with medical terminology. Consequently, this left patients unequipped to ask questions and compromised in their ability to participate in treatment decisions, thus contributing to treatment nonadherence. Altogether, participants felt this broadened the patient-provider divide and contributed to patient dissatisfaction, since patients often felt rushed, misunderstood, and unattended.

Patient-centered Strategies to Improve Quality Care

Participants offered many strategies to improve LEP patient care quality (see Figure 1). Themes primarily centered on empowering the patient while reinforcing the foundation of a medical system that serves a culturally and linguistically diverse population.

Figure 1.

Patient-centered Strategies to Increase LEP Patient Quality of Care

Improve access to interpreters

Participants thought hospital-wide efforts should be made to increase patients’ knowledge and awareness of free and confidential interpreter services. Specifically, they recommended that, at first entry into a clinic, patients should receive language-concordant visual aids highlighting their rights to free interpreters, defining the role of interpreters (e.g., voice vs. friend), describing methods for requesting interpreter services, and summarizing ways to effectively utilize an interpreter.

Teach basic health management processes

Participants imparted the need to educate patients about the U.S. medical system, including informing patients of their right to ask questions and to inform their physician of any discomforts. Suggestions included the creation of language-concordant materials that provide treatment-specific information and that describe the differing roles of their medical team; additionally, they recommended booklets wherein patients can maintain a list of medications, treatment history, questions regarding their cancer care, and provider names and contact information. Suggested communication improvements included instructing patients to be on time to appointments and to schedule an interpreter prior to their visit as well as using diagrams to reinforce patients’ understanding of their diagnosis and treatment.

Educate the provider

Participants recommended regular, hospital-wide trainings to increase staff and provider awareness of the utility of medical interpreters as well as strategies to integrate them into their practice. Further, participants felt it was important to increase providers’ awareness of cultural norms and their potential impact on patients’ diagnostic awareness and decision-making processes; particularly, efforts should be made to prioritize the need of patients while being mindful of familial roles, values, and preferences.

Empower the patient

Interpreters underscored the value of empowering the patient, which they defined as bestowing patients with the knowledge, skills, and resources necessary to become more active and effective players in their own healthcare. Specifically, participants believed patients should be informed of their right to ask questions.

Conclusion

LEP patients are highly susceptible to poorer quality care due to language barriers; however, there is little information regarding factors that may influence their cancer experience and the nature of cancer care delivery. Consistent with what has been documented in the literature [4,9], our sample of medical interpreters echoed similar themes they believed may impact the quality of care LEP patients receive in the cancer context, including system-level obstacles to service access, underuse of medical interpreters, and lack of patient understanding of the medical system and their cancer care. These themes both substantiate and build on existing findings by explaining, from the interpreter perspective, how these separate yet interrelated pathways may contribute to some of the disparities in LEP patient cancer care. Collectively, participants speculated that these factors increased the risk of communication errors and reduced patients’ capacity to engage in their cancer treatment. In essence, interpreters have the potential to strengthen the patient-provider dyad by providing patients with a medium to convey health concerns, symptoms, side effects, and treatment preferences. However, these findings suggest that the provision of interpreter services alone may be limited by deficits in patients’ understanding and involvement in their care. It is possible that, although interpreters may offer linguistic support, perceived gaps in patients’ knowledge and awareness of important health care management processes might preclude patients from fully comprehending medical transactions; in effect, patients may receive but be unable to adequately process and respond to the information provided. These results lend support for the development of interventions that target both language and knowledge barriers to improve the provision of equitable and quality cancer care for LEP patients.

In light of these reports, the interpreters offered a number of strategies to mitigate these challenges and thus optimize cancer care for LEP patients. Specifically, they stressed the need to educate patients by incorporating accessible resources, such as language-concordant informational aids (e.g., booklets and visual aids), into cancer clinics and patient encounters to increase patients’ awareness and use of trained interpreters, promote their understanding of their diagnosis and treatment, and facilitate their ability to actively engage in their cancer care. These interpreter-driven solutions slightly diverge from typical recommendations to address quality care barriers in that they are patient-centric. Specifically, although the interpreters acknowledged system-level obstacles to quality care delivery, these efforts center on activating patients and empowering them to overcome the linguistic divide and become more engaged in their treatment, which may help support the assimilation of Western medical practices into their own cultural framework.

Despite the novelty of these findings, this study has several limitations. Because this study recruited from a convenience sample of interpreters working in Boston academic medical centers, findings are limited in generalizability and may not reflect the opinions of interpreters beyond this sample. Further, although interpreters work closely with patients, patients may have alternate accounts of factors impacting their use of interpreters and their care during cancer treatment. As such, future research should be undertaken with patients to evaluate their reasons for declining interpreter services as well as assess their programmatic and care needs. Lastly, these findings highlight patient-empowering strategies to increase the quality of cancer care for LEP patients; however, it is important to acknowledge the role that the physician and medical establishment have in ensuring equitable and quality cancer care delivery across all patients. As such, this is only one facet of a multilayered approach that would be strengthened by integrating systemic and provider-level interventions to improve patient quality care.

In sum, access barriers, underuse of trained interpreters and limited patient understanding and interactions with their cancer care are important factors that may play a role in diminishing the quality of care LEP patients may receive during cancer treatment. One approach to addressing this multifaceted problem may include empowering patients by increasing their understanding of the U.S. medical system as well as improving their knowledge and use of medical interpreters. This notion of integrating medical interpreters into regular patient care has been underscored by the Department of Health and Human Services, who put forth recent initiatives to promote interpreter use to improve patient-physician communication and reduce healthcare disparities [10]. This movement is particularly critical in light of the changing landscape of the healthcare system. Specifically, with the enactment of the Affordable Care Act [11], increasing numbers of LEP individuals will have the opportunity and coverage to access needed healthcare services [12]. Accordingly, efforts directed at establishing patient-centered programs that incite use of language services offers one avenue by which to promote healthcare access and quality. Future studies would benefit from systematically examining the effects of these interventions on treatment satisfaction and treatment outcomes.

Key Points.

• ▪Patients with limited English Proficiency (LEP) may be susceptible to receiving lower quality cancer care.
• ▪Medical interpreters offer a unique perspective of patient experiences that can inform and equip cancer centers with tools to manage the complexities of diverse medical populations.
• ▪Our sample of professional interpreters identified a number of themes they believed contributed to lower quality cancer care among LEP patients, including system-based access barriers, underutilization of interpreter services, and limited patient understanding of the U.S. medical system; collectively, they believed these impacted quality cancer care by increasing the likelihood of communication errors and reducing patients’ engagement in their treatment.
• ▪Designing patient-centered interventions that incorporate accessible tools (e.g., visual aids) into cancer clinics may help empower patients, increase their use of interpreters, promote their understanding of their diagnosis and treatment, and facilitate their engagement in their cancer care.