Promoting quality care in patients with cancer with limited English proficiency: perspectives of medical interpreters
Year: 2016
Type: article
Abstract: Individuals with limited English proficiency (LEP) are a growing population 1. Patients with LEP 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. Patients with LEP diagnosed with cancer may be particularly susceptible to adverse outcomes as a result of 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 a 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 populations with LEP, little is known about additional factors that may influence the provision of quality care for patients with LEP and cancer, 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 patients with LEP and cancer. Moreover, this is among the first studies to solicit interpreters' recommendations for improving cancer care for patients with LEP. 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 patients with LEP. 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 patients with cancer 8. It was approved by the MGH/Partners HealthCare Institutional Review Board. In brief, interested interpreters who worked >20 h 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, the participants completed 30-min individual interviews using a semi-structured interview guide that elicited the interpreters' perceptions of factors that reduce patients with LEP's quality of care and strategies to enhance patient satisfaction and quality care, specifically in the cancer care context. 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 = 0.91). Approximately 29 interpreters participated in the study. A majority were women (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 six encounters with cancer patients daily. Three themes emerged related to the interpreters' perceptions of factors that interfere with the provision of quality cancer care for patients with LEP: (a) system-level factors; (b) underutilization of trained interpreters; and (c) gaps in patient understanding and interactions with the US medical system. Following are a summary of the major themes with corresponding quotes listed in Table 1. 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 as a result of staff shortages were commonly identified sources believed to impact the quality of cancer care that the patients with LEP received. Underutilization of professional interpretation services was unanimously introduced as a principal factor impacting the provision of quality patient care. Specifically, the 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, the participants acknowledged that patients did not effectively access professional interpreter services. When prompted for reasons for underuse, the 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. Generally, the interpreters found that patients struggled with understanding and engaging with the US medical system. The interpreters noticed that patients were unaware of the emphasis placed on patient care involvement in decisions about prescriptions, tests, or treatments. They observed that 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, the participants felt that this broadened the patient-provider divide and contributed to patient dissatisfaction, because patients often felt rushed, misunderstood, and unattended. The participants offered many strategies to improve care quality for patients with LEP (refer to 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. The participants thought that 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. The participants imparted the need to educate patients about the US 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. The 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, the participants felt that 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. 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 health care. Specifically, the participants believed that patients should be informed of their right to ask questions. Patients with LEP are highly susceptible to poorer quality care as a result of 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 that patients with LEP 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 cancer care for patients with LEP. Collectively, the 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 patients with LEP. In light of these reports, the interpreters offered a number of strategies to mitigate these challenges, and thus, optimize cancer care for patients with LEP. 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 patients with LEP; 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.
Source: Psycho-Oncology
DOI: 10.1002/pon.4176
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2430951222