Working with Linguistically Diverse Populations

A key to effective health promotion and service provision for linguistically diverse communities is implementing linguistically competent  policies, structures and practices. Implementing language access is, however, complex and requires knowledge, skills and resources. This feature of the National Center for Cultural Competence website is designed to provide answers to frequently asked questions about how to implement language access.

1.    What is language access?
2.    Why is it important?
3.    Do I have to do this?
4.    What is translation?
5.    What is interpretation?
6.    When do I need to have information translated?
7.    How can I find information on Sudden Infant Death Syndrome (SIDS) and Other Infant Deaths (ID) in other languages?
8.    How will I know if these materials work for my population?
9.    How can I find translation services and how will I know if they are any good?
10.  How should I work with a translator?
11.  Is it ever appropriate to create a non-English document from scratch?
12.  When do I need an interpreter and how can I find these services?
13.  Who will pay for interpretation?
14.  How do I learn to work with an interpreter?
15.  What are other language access resources?
16.  Where can I find demographic information on language needs in my state?
17.  What are some examples of how others have created language services for their programs or organizations?

1.  What is language access?

Many of us are familiar with the concept of access for people with disabilities --- being able to get to, use and/or benefit from services, such as restaurants, public buildings, transportation and so on.   Language access means that people who don't speak English very well or at all, are able to use and benefit from a wide range of services.  

2.  Why is it important?

Being able to access services such as education, legal services, health and mental health care is very important and in some cases can even be a matter of life or death. It is difficult to imagine effective treatment, health education, support or any interaction within the health or mental health system without effective communication.

It is estimated that about 11 million people or 4.2% of the population of the United States experiences some level of difficulty speaking English well to not at all.  Other estimates place the number of people with limited ability to speak English at least very well at more than 21 million, or 8.1 percent, of the U.S. population.  This is especially important when we think of families in households where no one over the age of 14 speaks English at least very well.  Such households are living in linguistic isolation.  In the United States there are about 11 million households or 4.7 percent of the population in this category.  It can be expected that these numbers will continue to increase, because of the changing demographics of the U.S. population.

Thus, health and mental health systems need to become more effective in providing language access. To this end, Title VI of the Civil Rights Act has been applied to the issue of providing language access. It requires that federally funded services make provisions to ensure that people who don't speak English well can still get to and use all these important services.   

3.  Do I have to do this?   

Yes.    If you receive federal assistance, then you are bound by federal requirements.  If you do not receive federal funds, you also should provide language access to effectively serve individuals and families who do not speak English well enough to participate meaningfully in encounters with your services and systems. Click here to learn more about the rationale for linguistic competence.

The Office of Civil Rights developed a video to explain the legal requirements regarding language access services according to Title VI of the Civil Rights Act of 1964.  The video explains the factors a program, practice, agency or organization that receives federal funding should consider when planning to provide meaningful access to programs and services.  The video also offers examples of language services.  To view it online, click here.

In addition, each state may have its own laws that support and require providing language access services.  The National Health Law Project wrote a report in 2003 that lists state statutes and regulations.  See www.healthlaw.org and click on Language Access.

The Office of Minority Health developed a set of standards for Culturally and Linguistically Appropriate Services (CLAS standards) primarily for health care organizations.  For a list of these standards, links to the full report, and other resources, see the Office of Minority web site at http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15

  4. What is translation? 

Translation usually refers to the written conversion of written materials from one language to another.  It is critical that translated materials not only replace information in one language with a set of words in a different language, but also convey the intended meaning of the original material.

5. What is interpretation?

Interpretation is the oral restating in one language of what has been said in another language.  When interpretation is successful the intended message and its meaning are appropriately conveyed.

6. When do I need to have information translated?

The Hablamos Juntos or We Speak Together project was funded by the Robert Wood Johnson Foundation to develop solutions for eliminating language barriers in health care.  Hablamos Juntos created guidelines to help people think through the process of whether or not to translate a document.  These guidelines and other helpful resources on translation can be found at http://www.hablamosjuntos.org/sm/default.to_translate.asp

There may also be legal requirements that impact the decision to translate materials. The U.S. Department of Health and Human Services wrote a guidance to support individuals and organizations that receive federal funds to provide services to the public, in understanding when they must provide language access services. In general, when 5 percent or 1,000 of a population group that you provide services to speak a language other than English, you must provide language access services.  It is important to remember to check with your state because each state may have its own rules about when you must provide translation and interpretation services.  For more information see the Guidance at: http://www.lep.gov

7. How can I find information regarding health and mental health and bereavement issues and SIDS/ID in other languages? 

In 2006, the NCCC collected information regarding SIDS risk reduction and bereavement support in languages other than English.   These materials have not been reviewed for scientific or language accuracy.

Click here for a list of Risk Reduction materials.

Click here for a list of Bereavement materials.

In addition, the National SIDS and Other Infant Death Resource Center keeps a listing of information and materials related to SIDS and other infant death, including those in other languages. See  http://www.sidscenter.org/ .

8. How will I know if these materials work for my populations?

There are variations in dialects of languages, differences from country to country and community to community and cultural differences among people speaking the same language. It is important to work with members of the local community to determine if materials in another language are appropriate for that group. The National Center for Cultural Competence developed a guidance document to help people think through how to choose, modify, or develop written materials for health promotion.  For a copy of this document, click here. 

Dr. Downing and Dr. Bogoslaw wrote a paper for Hablamos Juntos specifically on translation in the health care system entitled Translation as a Strategy for Effective Communication with Patients and Clients: A How-To Guide (April 2003).  This paper and other resources can be found under Translation and Quality, Written Materials at http://www.hablamosjuntos.org/resources/default.asp#tqwm

9. How can I find translation services and how will I know if they are any good?

Recent studies tell us that hundreds of languages are spoken in rural and urban areas of the United States. Understanding and processing information can be challenging for many people, this is especially true for those who do not speak English as a primary language.  Clear communication is essential to successful navigation of any service systems; since many service systems rely on written materials for conveying important information, materials translation can enhance communication, access and outreach to individuals, families and communities for whom English is not a primary language.

Translation services can be found in a variety of ways including but not limited to: 1) internet and yellow page searches, 2) translation companies or brokers, 3) language banks, 3) word of mouth and 4) by contacting community-based organizations such as community colleges, local hospitals, managed care organizations, refugee resettlement sites, and/or faith-based entities.   It is perfectly acceptable to request references, credentials and samples of translations (and English language source documents) from the perspective translator.  You can also ask the translator to do a half-page sample, but do offer to pay for the service.  Be prepared to contact references; and show the translation to a native speaker of the target language as a system of cross-checking.  Downing and Bogoslaw (2002, see www.hablamosjuntos.org) offer the following criteria for guiding translation and judging the finished translated product.  They state that the translation must be:

• Understandable; written at a suitable reading level, but also clear in concepts, implications and references that may be specific to particular cultural groups,

• Appropriate in approach, content, directness and style,

• Accurate in terms of how well the translation maintains faithfulness to the intent and facts of the original text.

A strategy for determining whether or not a translated document meets the above criteria, is to invite bilingual staff and community members to review the draft translation for the purpose of providing comments and feedback.  

10. How should I work with a translator? 

The beginning steps to working with a translator involve determining for yourself and/or your organization the following:

• What is the message/information to be conveyed?

• What are your needs regarding the translation (purpose)?

• Who the translation is for (the target audience: age, education, literacy, cultural beliefs)?

• What is the final product expected to look like (format or medium; fully ready for publication versus checked and edited prior to publication)? and

• How will the material be made available (dissemination strategy)?

Once the answers to the above questions have been identified and you have located a translator, share the information with him/her.  Inquire as to whether or not the translator provides editing services, and whether or not it is a part of the translation fee. Allow the translator time to review the material, ask you questions and develop a cost estimate for the project.  The translator may be a good source of advice regarding changes to the text to ensure that it is most applicable to the cultural and linguistic context of the target audience.   It is a good idea to have a native speaker or member of the target community check drafts and/or the final product to verify the translations faithfulness to the intent, content and cultural context of the original source document. 

Several sites offer useful information and tips related to working with translators.  The Carolina Association of Translators & Interpreters (CATI) offers A Guide to Working with Professional Translators available at http://www.catiweb.org/working6.htm

The Japan Association of Translators provides a wealth of information about translators and translations at http://www.jat.org/translatorsearch/workingwithtrans-e.html

The Hablamos Juntos project provides Translation Basics at http://www.hablamosjuntos.org/sm/default.translation_basics.asp.  Additional materials related to the preparation of a translation brief (brief information to assist a translator in understanding the needs, nature and expectations of the material to be translated) is directly available from this site.

11. Is it ever appropriate to create a non-English document from scratch?

Yes.  In fact, current research is indicating that creating appropriate new materials in the target language of the intended audience may be a preferable alternative to translating a document that already exists in English.   Collaboration with a bilingual/bicultural writer is essential to the development of non-English documents, in terms of ensuring that the content, message and style of the document have cultural meaning for the target audience. The Hablamos Juntos website offers guidance and suggestions regarding the development of non-English documents.  Such information can be found at the following location http://www.hablamosjuntos.org/sm/default.index.asp

Additional information is available in the article Effective Patient-Provider Communication Across Language Barriers: A Focus on Methods of Translation, also from www.hablamosjuntos.org

12. When do I need an interpreter, and how can I find these services?

An interpreter is needed whenever there is an interaction with and individual, family or group who do not speak English well, very well or who indicate that they will need an interpreter to fully participate in a health or mental health interaction. Again, Title VI provides guidelines related to legal requirements. The guidance developed by the U.S. Department of Health and Human Services addresses why and when federally funded organizations, providing services to the public must provide language access services (oral interpretation and/or translation of written documents). Basically, when 5 percent or 1,000 of a population group that you provide services to speak a language other than English, you must provide language access services.  Check with your state regarding its language access requirements.

Sometimes programs utilize what are known as ad hoc interpreters. These interpreters are not trained as medical interpreters and may not be familiar with legal and ethical issues such as confidentiality.  Ad hoc interpreters may be staff who are bi-lingual or family or friends accompanying the patient or family. (Children should NEVER be used to interpret.)  While ad hoc interpreters may be better than none, their use is problematic. Ad hoc interpreters may not know technical medical terms, may not understand their neutral role in the interaction and may even try to spare the patient from bad news.  Trained interpreters have the skills and knowledge to assure an effective and accurate interpretation.  Providers and programs can help staff ad hoc interpreters to gain the preparation and skills needed to become trained or professional interpreters.

Providing interpretation services requires advance planning. In an effort to prepare your program, agency or organization for working with individuals and families from diverse language backgrounds you might consider first:

• Identify someone in your program, agency or organization that will be responsible for language activities.

• Assess the language needs of the community and the individuals that you serve using the four factors described in the guidance issued by the Department of Health and Human Services, Office for Civil Rights including:

1.      The number or proportion of persons of limited English Proficiency (LEP) eligible or likely to seek services;

2.      How often the individuals will come into contact with your program;

3.      The nature and importance of the program to people's lives; and

4.      The available resources and costs.

• Ask the people that use your services about their written and oral language needs.

• Keep data on language needs in records and program, agency or organizational databases

• Identify and examine existing community resources that provide in-person or telephone interpretation and/or written translation.  Consider contacting court systems, immigrant organizations and refugee resettlement programs, community colleges and universities and other community-based organizations.  The National Council on Interpretation in Health Care (http://www.ncihc.org) offers a variety of resources and lists local interpreting organizations.

• Decide on the language services to be provided  (in-person, telephone, contract interpreters, trained bilingual staff) and at what points of contact (at the reception desk, when calls come in, during service provision, responding after hours- answering machines or services)

• Develop a plan and discuss the plan with all staff; provide staff training about policies and procedures for accessing language access services for clients/patients.

• Notify persons of limited English proficiency that language services are available by posting information in the needed languages in offices, and disseminating information via flyers, newsletters, and materials for new clients/patients.  

The Hablamos Juntos website features some of the new and innovative practices developed by 10 project demonstration sites to address language barriers for Latino/Hispanic populations http://www.hablamosjuntos.org/resource_guide_portal/demonstration_sites/default.grantees.asp

13. Who will pay for interpretation?  

According to the Access Project, the Centers for Medicare and Medicaid authorized states to use Federal Medicaid and SCHIP funds for language activities and services, permitting states and providers to submit these costs for partial reimbursement.  (See http://www.accessproject.org/language.html , Language Services Action Kit, page 12).  This kit also provides information for people to advocate in their states to use Medicaid and SCHIP funds for language services.

Hablamos Juntos addresses issues in paying for language services in the document entitled:  Affordable Language Services:  Implications for Health Care Organizations.   See http://www.hablamosjuntos.org/resource_guide_portal

14. How do I learn to work with an interpreter?

Collaborating with interpreters is an effective way to reduce communication barriers with individuals and families with limited English ability.  Working with an interpreter requires awareness, knowledge and skill in facilitating a three-way communication. 

Be aware that:

• The individual or family is the focus of the conversation- face the individual or family and speak directly to him/her or them; maintain eye contact and communication with the individual or family. 

• The interpreter is an extension of you- he/she is a conduit for information; as such the interpreter should convey the message and meaning of the information as you have stated it, but within the appropriate cultural context.

Know and understand that:

• The interpreter may require additional time to convey your message; pace your conversation, speaking slowly and clearly in a regular voice.

• The patient may need clarification- allow time for the individual or family to repeat information and/or ask questions

Demonstrate skill by:

• Conferencing with the interpreter- to discuss and agree upon roles, goals and expectations for the three-way encounter; review and discuss the presenting problem and/or terms that may be part of the encounter; as well as strategies for conveying information when there is no word to describe the term in the patient's native language.

• Setting the scene- arrange the environment to facilitate communication- such that the individual or family is facing you and the interpreter; introduce the interpreter to the individual or family; and explain what the interpreter will be doing. 

• Using simple language- and straightforward sentences; communicate information at a level that the individual or family can understand; avoid jargon when possible; use short precise questions; ask for repetition or clarification of information; ask for explanations, especially when there is a culturally linked issue or concern; if an exchange continues for an extended period, indicate to the speaker to stop to allow for interpretation.

• Observing the individual or family- look for nonverbal cues when interpretation is occurring;  if you feel that the individual or family has not fully understood information or instructions given, ask him/her or them to repeat the information or instructions to ensure for complete comprehension and interpretation.

Additional information for working with interpreters is available from multiple sources.  Visit New York University's Center for Immigrant Health's web site at http://www.med.nyu.edu/cih/

Online Training for Doctors on Working with Interpreters. This program, developed by Cindy Roat and Dr. Liz Jacobs, confers up to 21ž2 CME credits through Rush Medical College. It uses video and case studies to train doctors on: how to work with professional interpreters, how to guide an untrained interpreter, how to work with a telephonic interpreter, how to work with interpreters in mental health settings, and how to start to develop a language access program internal to a hospital or clinic. The program costs $15 per credit, and there are discounts available for bulk orders. For more information, contact Bob Amend at 520.722.1970 or via email at bamend@md-inc.com

Cross Cultural Health Care has many resources to assist in working with interpreters.   They also train interpreters. See http://www.xculture.org/ for these resources.

15. What are other resources?

New! The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) launched a new program in March, 2007, Effective Communication in Hospitals, to assist hospitals in meeting the communication needs of individuals who do not speak English as their primary language (i.e. are limited English proficient) or who are deaf or hard of hearing. See http://www.hhs.gov/ocr/hospitalcommunication.html

Let Everyone Participate, a website from the Federal government that has resources and information on meaningful access for people who have limited English proficiency.   This is a good one-stop spot for the latest policies and guidelines from the Federal government.   This site also offers opportunities for technical assistance, information and help with specific questions.  It also has demographic information and links.  See http://www.lep.gov/

The Department of Justice has posted the full text of the Executive Order 13166, which is the order from the President requiring that federally conducted and federally assisted programs and activities take steps to improve access to their services for people with limited English proficiency.  This site also has memos that offer specific guidance on how to implement this Executive Order.    See http://www.usdoj.gov/crt/cor/13166.htm.

The National Health Law Project has good resources, reports, and current information on language access topics.  See www.healthlaw.org and click on Language Access.

Grantmakers in Health (GIH) developed two documents that advocate for language access.   They both contain useful information on the scope of needs in this area.  Visit http://www.gih.org and search for these publications:  Improving the Language of Health  &  In the Right Words: Addressing Language and Culture in Providing Health Care. 

16. Where can I find demographic information on language needs in my state?

Several websites offer state and national information to aid in acquiring information about the languages spoken in the United States.   The Modern Language Association (MLA) offers a Language Map Data Center with a searchable database that provides language data for the entire US, and by state, county, and zip code.  Information can be obtained by language or by most spoken languages in a state.  Visit the MLA web site at http://www.mla.org/census_data

Grantmakers Concerned with Immigrants and Refugees (GCIR) provides a map of information on each state including general information on how many foreign-born persons live in that state and what is the language spoken at home.   See http://www.gcir.org/about_immigration/usmap.htm.  This is a good place to start to find information about your state.  

The Census Bureau website provides a wealth of information at the national, state, and local levels.  Information can even be searched by city, county census tract and zip code.  Visit the Census Bureau web site at the following sites:

http://www.census.gov

http://www.census.gov/population/www/socdemo/lang_use.html.

http://factfinder.census.gov/servlet/SAFFPeople?_submenuId=people_8&_sse=on

http://factfinder.census.gov/home/saff/main.html?_lang=en&_ts

The Census also collects and provides information about languages spoken at home.  In the United States a considerable number of people report speaking two or more languages.   Many who report speaking a native language at home also report speaking English very well.  The Census offers a chart that provides a portrait of languages spoken and English ability

Still a sizeable number of people speak English less than very well and some do not speak English at all.  The Census web site provides information on English ability at the following site

Linguistic isolation is a term the Census Bureau uses to describe households in which no one over age 14 speaks English very well.    Follow the Census link below for  information on linguistically isolated households, per state.   http://www.census.gov/population/cen2000/phc-t20/tab02.pdf

17. What are some examples of how others have created language services for their programs or organizations?

The National Council on Interpreting in Health Care wrote a paper describing different models for providing language services in health care systems. See http://www.ncihc.org/workingpapers.htm

The National Conference of State Legislatures Children's Policy Initiative sponsored a paper by Ann Morse entitled Language access:  Helping Non-English speakers navigate health and human services. This contains examples of State programs and promising practices.     See http://www.ncsl.org/programs/immig/immighealth.htm