Bilingual Call Interpreters vs. Family Interpreters for Hispanic Diabetic Patients

Introduction

Elderly Hispanics between the ages of 50 and 75 who are only proficient in their native language are referred to as Limited English Proficient (LEP) patients. As a result, they are disenfranchised by the language barrier, which often necessitates the use of an interpreter. In urgent medical cases, ad hoc interpreters — who are often family members — act as intermediaries between the patient and the physician. However, standard procedure, as stipulated in NSW policy, calls for professionals such as bilingual call interpreters to offer interpretive services under such circumstances.

This inherent challenge limits the LEP patient's receipt of primary and preventative care. The challenge is especially prevalent among elderly Hispanic immigrants and Mexican Americans. There is an 18.3% prevalence of diabetes among Hispanic communities for both undiagnosed and diagnosed patients, driven in part by predisposition to diabetic disorders due to cardiometabolic abnormalities. This is considerably higher than the 10.2% prevalence among non-Hispanics. The management of diabetes requires close correspondence with a physician, including keeping personal records, managing nutrition, and maintaining personal knowledge about quality of life. The role of an interpreter is to ensure that patients receive the same quality of health care as English-speaking patients — or better. The use of a bilingual call interpreter carries the advantage of professionalism compared to family interpreters. This paper examines whether the use of a bilingual call interpreter during a provider visit, compared to utilizing family members as interpreters, improves medication adherence over a three-month period.

Background and Problem Statement

Currently, there are more than 50 million Hispanic residents in the United States. Research conducted by the National Heart, Lung and Blood Institute identified a significant knowledge gap in the population regarding the development of chronic diseases among Hispanic communities. The study found a high prevalence of diabetes, low rates of awareness and disease control, and limited health insurance coverage ("Diabetes among Hispanics: All Are Not Equal," 2014). While these challenges already pose a serious health risk to the elderly, language barriers present an additional impediment to the delivery of health services.

One-on-one interaction with a doctor is essential both for the patient's ability to articulate their health concerns and for the physician's understanding of the presenting problem. The exchange between provider and patient is diagnostically and therapeutically important. However, language barriers necessitate a third party to facilitate communication between the LEP patient and the health provider (de Moissac & Bowen, 2017). That third party could be a bilingual interpreter in person or by telephone, a family relative who is proficient in English, or someone using a handheld translation device. In some cases, communication relies on the family interpreter's limited comprehension of English. Managing quality health care under these circumstances makes it difficult to adhere to the standards articulated in NSW policy.

Engaging a professional translator introduces a range of dynamics that can affect the process differently. Occasionally there is conflict between professional perspectives, where bilingual interpreters overstep their role and engage in the treatment process itself (Bethea, 2018). Such conflict in the definition of the interpreter's role may ultimately work to the disadvantage of the patient. There are also instances where the doctor feels that their concerns are not being conveyed to the patient as intended. The patient may also find it difficult to engage a stranger as a third party in their treatment, which introduces another factor the provider must consider when deciding which interpreter to use. Additionally, the patient may not have health insurance that covers professional interpreter expenses, or may be unable to meet the costs of such services.

There are no well-developed systems designed to address the challenges that language barriers create in the administration of health services to LEP patients. Patients who need interpretive services are often unaware of their importance and therefore do not seek insurance coverage for language assistance. Regulators are also uncertain whether such services carry any measurable clinical value. Insurers, meanwhile, are conflicted about whether language assistance should be considered a benefit, and the metrics for evaluating linguistic translation services present numerous challenges (Hu, Wallace, McCoy, & Amirehsani, 2013). When linguistic services vary by clinical context, culture, and geography, they create problems of cost and feasibility. As a result, family interpreters or other ad hoc interpreters are likely to continue filling the interpretation role.

Elderly diabetic patients are also prone to a range of social factors — such as retirement, low physical activity, loss of interest, and lack of close caregivers — that contribute to the high prevalence of diabetes in this age group. Active diabetes management is core to maintaining optimum glycemic levels. It requires close monitoring of diet and physical activity, practicing healthy living, and maintaining a positive psychology toward quality of life in order to avoid negligence (Jacobs et al., 2006). However, active management becomes nearly impossible for patients who have no close caregivers and lack comprehensive insurance coverage that includes linguistic translation services. The financial capacity of elderly LEP patients is often a further limiting factor. Teaching patients self-management practices and engaging them outside the clinical setting is also extremely difficult given the language barrier and the cost of linguistic assistance services.

Problem statement: To evaluate whether the use of a bilingual call interpreter during a provider visit, compared to utilizing family members as interpreters, improves medication adherence over a three-month period among diabetic Hispanics between the ages of 50 and 75.

Research Gaps and Historical Perspectives

There is limited research on the financing of linguistic assistance services. Little has been documented about the cumulative costs associated with the administration of linguistic services or about the efforts made to reduce those costs as a barrier to access. The efficacy of linguistic intervention in the administration of healthcare has not been comprehensively studied (Jacobs et al., 2006). There is a clear need for more thorough research on the impact of language barriers on the quality of healthcare and on how the use of linguistic interpreters affects service delivery. With an estimated 13% growth in the immigrant population in the United States by 2050, in-depth research in these areas will be important for informing policymakers about the significance of both the current situation and the challenges ahead.

In a study conducted by the Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE), researchers sampled a population of 3,050 adults aged 65 years or older. The research design allowed respondents to answer in either English or Spanish. Participants were native Mexican Americans or immigrants, and the immigrants were further classified as first-, second-, or third-generation respondents (Jacobs et al., 2006). Participants were also assessed for diabetes and classified as baseline diabetic, borderline diabetic, or definite diabetic. They were asked to provide any family history of diabetes and to share information about their educational background as a socioeconomic indicator.

The findings showed that the prevalence of diabetes was highest among third-generation Hispanics, followed by second-generation Mexican Americans, and then the first generation. Preferred language did not present a significant difference in diabetes prevalence. Educational attainment varied across generational segments. Third-generation members were more likely to hold high school diplomas and to have private or Medicare health insurance coverage. Older generations were more likely to prefer responding in Spanish, often had little or no formal education, and were less likely to have insurance coverage. Third-generation respondents and those who answered in English were more likely to be insured (Afable-Munsuz, Mayeda, Pérez-Stable, & Haan, 2013). Each subsequent generation after the third was more likely to respond in Spanish, to lack insurance, and to have low or no educational qualifications. These findings suggest that language barriers are most prevalent among first- and second-generation Hispanics who preferred to respond in Spanish — the same group most likely to face financial barriers to healthcare due to lack of insurance.

There are more than 25 million Americans who are not proficient in spoken or written English, and more than 100 languages are spoken across the country. Given this pronounced linguistic diversity, there are not enough interpreters nationally to serve every health institution. This gap has resulted in the widespread use of telephone interpretation services, through which physicians contact a language provider and receive interpretive assistance remotely (Juckett & Unger, 2014). Providers such as CyraCom Language Solutions and Language Line are often contracted by health organizations to render interpretation services by telephone. They may also offer translation services or assist organizations in developing appropriate internal approaches.

Regulation on the use of interpreters has been introduced to establish standards in the administration of interpretation services. Title VI of the Civil Rights Act of 1964 requires all federally funded entities to provide linguistic services to LEP patients (Jacobs, Chen, Karliner, Agger-Gupta, & Mutha, 2006). Many states have also enacted regulations specifying the importance of linguistic services for LEP patients, although these are rarely enforced consistently. The lack of enforcement stems from the feasibility challenges and costs involved, which vary with the size and capacity of the health facility. Because the patient mix and LEP population served differ across organizations, the blanket policies stipulated in the Civil Rights Act and state regulations are not always feasible. Health facilities frequently contest this mandate because public and private insurers rarely reimburse them for these services — meaning the constitutional obligation comes without a corresponding financial plan.

Conclusion

Language barriers, as established, present a range of significant challenges in the administration of healthcare services to LEP patients. As a result of this inherent challenge, they face more negative health outcomes than patients who are proficient in English. Managing diabetes among elderly patients between the ages of 50 and 75 requires close medical mentorship, yet this process is complicated by the costs incurred for linguistic access services. In an effort to ensure that patients receive standardized care, professional interpreters should be sought in order to minimize the risks associated with misinterpretation. Professional bilingual call interpreters promote improved diabetes management by increasing adherence to healthcare plans and ensuring the consistent observation of healthcare recommendations.

The use of third-party interpreters — whether in person or by telephone — has an overall cost-effective impact, as improved diabetes management can be expected to reduce emergency room visits and hospital admissions. However, there is a clear need for the development of a robust financial and legal framework to insure LEP patients and to establish comprehensive policy for the delivery of linguistic access services.

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