Print-Based Language Aids

For the purposes of this document, print-based language aids refer to the spectrum of “commercial off-the-shelf” (COTS) technologies, graphic or text-based, that may assist in communication. In the United States, picture-based tools have demonstrated a positive impact on health-care outcomes. In a randomized emergency room setting, for example, access to such guides resulted in English-language providers being more than twice as likely to identify a non-English speaking patient’s primary medical concern. ^{Reference Dowse20} In the same study, the risk of catastrophic medical errors due to unrecognized patient medication allergies was also significantly reduced.

Pictograms are descriptive symbols that are designed to help convey information or instruction. Unlike written or verbal communication, they are expected to be understood by speakers of different languages. Their use helps to reduce the amount of reading required and motivates patients to follow medication instructions, therefore, leading to a positive effect on the patient’s ability to recall and retain medication instructions. ^{Reference Sorfleet, Vaillancourt and Groves21} Pharmacists in the Military and Emergency Pharmacy Section (MEPS) of the International Pharmaceutical Federation are involved in providing humanitarian care for patients, often where they do not have a language in common. For these reasons MEPS developed a project to design and develop pictograms to label medications. Research has shown that the use of pictograms along with text leads to improvement in understand of health information across a variety of both disease processes and cultural/geographic areas. ^{Reference Malhotra, Bautista and Tan22 – Reference Grenier, Vaillancourt and Pynn24} Therefore, pictograms can be a valuable tool to help bridge the gap in communication that can exist between HUMRO providers and patients.

Graphic aids are generally easy to use, easily accessible, and inexpensive, but they do have potential limitations. In the case of images or pictograms generated by software, having access to a computer, a printer, even the Internet for solutions only available online, may pose a logistical challenge in many situations where HUMRO are conducted. An individual’s cultural background will influence their ability to interpret “standard” representations of physical and/or psychological symptoms. ^{Reference Place25} A recent study conducted by Clawson and colleagues investigated the efficacy of pictorial representations among 186 medical humanitarian assistance providers assigned to a US Navy Hospital Ship Medical Civic Action Program (MEDCAP). In their analysis, pictograms were reported as useful aids for conveying simple concepts such as medication schedules or instructions on how to properly use a medical device. They noted, however, that nonnative English speakers as well as people from different cultural backgrounds interpret pictorials representing complex ideas differently. ^{Reference Clawson, Leafman and Nehrenz26}

The interpretation of pictograms by patients will also be affected by the context around the population in which the pictograms are being used. In areas were the only potable water is available through water bottles, a pictogram depicting drinking water coming from a faucet may not be understood and vice-versa. Pictograms used to warn about avoiding the use of alcohol are also highly influenced by the context in which the population accesses alcohol. In several countries and regions, a bottle of wine or a can of beer will be easily understood as depicting alcohol. In other regions of the world where alcohol is mainly artisanal and available in jugs or jerry cans, the pictogram would differ greatly. ^{Reference Grenier, Vaillancourt and Pynn24}

Text-based medical phrasebooks are another commonly used print-based language aid. They have been advocated as effective and inexpensive communication adjuncts during international operations. ²⁷ Many phrasebooks are organized by symptom cluster or by physiologic system, reducing the length of time required for a provider to find related follow-on questions to ask their patients. ^{Reference Chan, Alagappan and Rella28} Limitations of this technology include the need for patients to have an adequate level of health literacy and the potential difficulty in matching patient answers to available pretranslated phrases.

Information Technology

The use of information technology (IT) to bridge the language gap in HADR operations is becoming increasingly common. Machine Foreign Language Translation (MFLT) algorithms have advanced considerably beyond simple word translation and are increasingly able to decode meaning in 1 language and re-encode the same meaning in another language. IT solutions to patient/provider language discordance have begun to shift from literal translation (word-for-word) to a more interpretative capacity. IT solutions are available that allow providers and patients to interact in the languages of their choosing by means of touch screen interfaces while their selections are instantaneously translated to speech in a language their counterpart can understand. ^{Reference Ong29} Like print-based pictorial representations, however, icon-to-speech technology is limited by the available preprogrammed response selections, and the difficulty in expressing complex medical processes through icons.

Two-way speech-to-speech (S2S) foreign language communication software is the desired end goal of many MFLT developers. In the United States, the Defense Advanced Research Project Agency (DARPA) has led the way in developing S2S technology through the Spoken Language Communication and Translation System for Tactical Use (TRANSTAC) initiative. Although these platforms were designed specifically for the US DOD war-fighter community, they are currently operating with over a 100,000 word capacity and are increasingly including some medical terminology to the lexicon. ^{Reference Weiss and Schlenoff30}

To specifically design and validate medical S2S capabilities, researchers at the Telemedicine and Advanced Technology Research Center (TATRC) began the Medical Application of Speech Translation (MAST) program. ^{Reference Rominiecki31} They have benchmarked over numerous COTS S2S applications in a capability gap analysis and have identified 3 main shortcomings of currently available systems: (a) insufficient vocabulary specific to the health/medical domain; (b) lack of publicly available evidence to demonstrate effectiveness, and (c) need for independent validation of software function.

The field of IT solutions for communication needs is rapidly progressing and is likely to provide significant benefits for medical providers deploying in support of HUMRO missions. At present, however, most commercially available platforms remain limited in their ability to correctly interpret medical conversation, although they are increasingly proficient at word-for-word factual translation.

Bilingual Responders

In some situations, the availability of bilingual staff can provide an element of built-in interpretation capacity. The strategy of recruiting bilingual responders was used successfully by many organizations in response to the 2010 Haiti earthquake. United States based disaster relief organizations were able to recruit medical staff that spoke speak French and/or Creole and used these responders to bridge the communication gap before local interpreters could be identified. ^{Reference Babcock, Theodosis and Bills32} A major advantage of using bilingual workers is that they can understand the cultural context of conversation and address the cultural implications of events as they occur in real-time. ^{Reference Lee, Sulaiman-Hill and Thompson33}

In other disaster relief operations, recruiting bilingual staff as a communication strategy has been less successful. In the recovery phase of operations after the Asian tsunami of 2004, the Australian government deployed a specialized team to provide medical care and conduct public health assessments. This team recruited 2 self-identified team members with the intent of having these individuals assist in an interpretative capacity. In their after-action report, the team noted that affected nation peoples were “distressed by their inability to communicate” effectively despite the presence of embedded ad hoc interpreters. ^{Reference Samarasinghe34} This finding is in keeping with a larger synthesis of opinion regarding medical disaster relief operations in response to the 2004 Asian Tsunami, which concluded that, to be effective, bilingual staff required high fluency in the language, cultural competency, and “a mastery of medical vocabulary.” ^{Reference Temple35}

The Australian experience indicates that the combination of cultural appropriateness, expert fluency, and medical competency may not be universally present among self-identified bilingual providers. In fact, these qualities may need to be specifically recruited for among bilingual providers. In support of this statement, a comprehensive analysis of the international relief effort in response to the Asian tsunami specifically noted that “a predominance of inappropriate ‘Western’ profiles, with poor language skills and an inadequate understanding of context and culture” bore significant responsibility in dampening response effectiveness. ^{Reference Behar, Benson Ii and Kurzweil36}

If appropriate bilingual providers can be identified, the preferential use of these members might introduce a selection bias within the team that needs to be acknowledged (ie, selecting for immigrant medical providers may influence how the team interacts with disaster-affected peoples). This is an important consideration as there are no assurances that language proficiency equates to being culturally representative of a community. ^{Reference Karliner, Jacobs and Chen37} This concern is the basis for UNHCR’s recommendation to recruit local nationals rather than relying on bilingual responders. ³⁸ This policy, however, may encourage highly skilled local nationals to move from their usual areas of employment toward the higher salaries earned in support international HADR operations.

Using Medical Interpreters

In the aftermath of a disaster/humanitarian emergency, identifying skilled host-nation interpreters can be a significant logistical challenge. Medical planners should be aware that, even if a sufficient number of interpreters are identified, securing access to these resources may not equate with solving communication issues. In the domestic setting, medical providers routinely underuse interpreters when they are readily available, even if the provider recognizes their insufficient language skills may be compromising clinical care. ^{Reference Diamond, Schenker and Curry39}

Part of the underuse of interpreters may be due to a training deficit on how to effectively use available interpreters. In a nationally representative study of US resident physicians, over half of all respondents claimed never to have received training on effective strategies for interpreter use. ^{Reference Lee, Winickoff and Kim40} A survey of curricula demonstrated the majority of US and Canadian medical schools do not provide formal instruction on the effective use of interpreter services. ^{Reference Kalet, Mukherjee and Felix41} Professional certification, therefore, cannot be used as a reliable marker for the ability to work with interpreters either in the domestic or international settings. It has also been established that providers who do receive targeted training on the negative impact of language barriers will engage with interpreters more effectively. ^{Reference Karliner, Perez-Stable and Gildengorin42}

In the context of HUMRO, interpreters may take on helpful roles beyond enhancing patient-provider communication. Babcock and colleagues highlight some of these additional interpreter roles to include the following: (a) leveraging interpreter contacts for public health disease surveillance; (b) using interpreters to provide culturally appropriate health risk communication messages; and (c) using interpreter contacts as a source of “on-the-ground medical intelligence” to help direct aid. ^{Reference Babcock, Theodosis and Bills32}

These additional roles were evident in the aftermath of the 2010 Haiti earthquake when interpreters actively assisted in tracking down patients’ relatives when immediate family members were missing or presumed deceased. ^{Reference Powell and Pagliara-Miller43} In view of these expanded roles, training on effective interpreter use should include exposure to the entire spectrum of value-added services an engaged interpreter staff may provide.

Working With Interpreters in the Context of HUMRO

Much of the training on how to best work with interpreters domestically is grounded in the utilitarian model theory where interpreters act as passive/unobtrusive factual translators. ^{Reference Hsieh and Kramer44} In a guide for the successful use of interpreters during domestic disaster and crisis responses based on his own operational experiences, Greenstone (2010) endorses the utilitarian method by advocating that:

The expectation is that interpreters will not influence the content of patient-provider interactions, a powerful method of preserving the traditional patient-provider relationship that reduces error by focusing on factual interpretation. ^{Reference Pollabauer46,Reference Flores, Abreu and Barone47}

In the setting of HUMRO, however, interpreters are often required to provide both effective communication (factual translation) and socially competent communication (cultural interpretation). This requires that providers establish a strong rapport with their interpreters to be confident that they will intervene in provider-patient interactions to achieve effective, ethical, and culturally sensitive communication. ^{Reference Farooq and Fear48} Using interpreters as cultural brokers, however, means accepting an increased risk of interpretation error as speech becomes culturally editorialized by the interpreter. Providers must acknowledge the limitations of this approach, especially when using untrained interpreters which, regardless of the interpreter model adopted, have been shown to compromise clinical outcomes. ^{Reference Flores, Abreu and Barone47 , Reference Bauer and Alegria49 , Reference Flores50}

The US National Center for Disaster Medicine and Public Health (NCDMPH) has published a “disaster health pocket card tool” with practical suggestions on how to work with interpreters. ⁵¹ Although domestically focused, these recommendations are relevant and are structured using a “before-during-after disaster” construct that lends itself to be easily incorporated into routine HADR training cycles.

Authors Recommendations for Bridging Language Barriers for HUMRO Providers