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Literature, papers, reports, and data

This section includes papers and reports gathered and produced during the planning and implementation phases of Hablamos Juntos. These materials represent what was known at the time the reports were written, but may not reflect the program’s final findings, which will be available on this website in September 2005.

These papers, reports, and data fall into the following categories:

The State of Health Care for LEP

1.37 Partida, Y. "Language Barriers and the Patient Encounter" Virtual Mentor - Medicine and Society, v9 n8: 566-571(2007) An explanation of difficulties created by language barriers in the medical encounter between patients and health care professionals. Interpreters, while necessary, may also affect the patient physician relationship.

1.36 Marsha Regenstein, PhD and Donna Sickler, MPH Race, Ethnicity and Language of Patients Hospital Practices Regarding Collection of Information to Address Disparities in Health Care. (January 2006). A study was conducted by the National Public Health and Hospital Institute (NPHHI) with support from The Robert Wood Johnson Foundation.

1.35 "Doctors Are Taking Language Classes: Communication with patients who don't speak English becomes a priority" by Laura Girresch, St. Louis Post-Dispatch December 7, 2006. The article talks about a doctor at St. Louis Children's Hospital who was visiting a Spanish-speaking woman who just had a baby who tried to tell her that her infant had jaundice. As he searched for the Spanish word for yellow, which is amarillo, something close to "animal" came out. That was all the woman needed to hear to think she had given birth to an animal and became hysterical for about 45 minutes. She calmed down when the hospital called interpreters from a department at Barnes-Jewish Hospital.

1.34 Flores, Glenn, MD., “Language Barriers to Health Care in the United States” The New England Journal of Medicine, Volume 355, Number 3, pages 229 – 231, July 20, 2006. This paper talks about how language barriers can have harmful effects on Limited English Proficient Patients as well as providers. These conclusions are supported by a consistent body of research demonstrating cases where either no medical interpreters where available or misinterpretation occurred resulting in lawsuits against hospitals.

1.33 Elizabeth A. Jacobs, MD, MPP, Alice HM Chen, Leah S. Karliner, MD, Niels Agger-Gupta, and Sunita Mutha. The Need for More Research on Language Barriers in Health Care: A Proposed Research Agenda. The Milbank Quarterly, Vol. 84, No. 1. (2006). This article describes what is currently known about language barriers in health care and outlines a research agenda based on mismatches between the current state of knowledge of language barriers and what health care stakeholders need to know.

1.32 Nelson, Roxanne "Residents Make Inadequate Use of Professional Interpreters", New research does not abode well for cross cultural care of non-english speaking patients. PainMedicine News, Clinical Pain Medicine. McMahon Publishing Group. V04:06 (December 2006)

1.31 Hasnain-Wynia, R., Yonek, J., Pierce, D., Kang, R. &  Hedges-Greising, C. "Hospital Language Services for Patients with Limited English Proficiency: Results from a National Survey." (2006). Health Research Educational Trust, National Health Law Program, The California Endowment. This report describes current practices, common barriers, and the specific resources and tools needed to provide language services to patients with LEP.The results of the survey will inform federal policymakers, practitioners, providers, and others of the issues and potential solutions facing hospitals as they work to improve language services for all patients with LEP.

1.30 National Initiative for Children's Healthcare Quality (NICHQ). Improving Cultural Competency in Children's Health Care: Expanding Perspectives. (July 2005). This report examines steps to address disparities in children's health care and to advance the ability of organizations to provide culturally competent care.

1.29 Adam L. Cohen, MD, MPH; Frederick Rivara, MD, MPH; Edgar K. Marcuse, MD, MPH; Heather McPhillips, MD, MPH; and Robert Davis, MD, MPH. (September 2005). Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients?

1.28 Elisabeth Wilson, MD, MPH, Alice Hm Chen, MD, MPH, Kevin Grumbach, MD, Frances Wang, MS, Alicia Fernandez, MD. Effects of Limited English Proficiency and Physician Language on Health Care Comprehension. Journal General Internal Medicine V20: Pages 1525-1497. (April 2005). This study explores the effect of limited English proficiency on medical comprehension in presence and absence of language-concordant physicians.

1.27 Flores, Glenn, M.D., Abreu, Milagros, M.D., and Sandra C. Tomany-Korman, M.S. (July 2005). Limited English Proficiency, Primary Language at Home, and Disparities in Children’s Health Care: How Language Barriers are Measured Matters. Public Health Reports, 120 (4): 418–30. This brief report summarizes the Commonwealth Fund study’s findings and concludes that LEP is more useful than language spoken at home in gauging the impact of language barriers in children’s health care.

1.26 Elizabeth A. Jacobs, MD, MPP; Kelly Karavolos, MA; Paul J. Rathouz, PhD; Timothy G. Ferris, MD, MPH; and Lynda H. Powell, PhD. (August 2005). Limited English proficiency and breast and cervical cancer screening in a multiethnic population.

1.25 Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. U.S. Department of Health and Human Services. (2005).

1.24 Leah S. Karliner, MD, Eliseo J. Pérez-Stable, MD, Ginny Gildengorin, PhD. The Language Divide, The Importance of Training in the Use of Interpreters for Outpatient Practice. Journal of General Internal Medicine, Volume 19:175–183. (February 2004) Communication difficulties affect the ability of physician residents to understand symptoms and treat disease, as well as their ability to empower patients regarding their healthcare. The study concludes that training providers in the use of interpreters may improve communication and clinical care, and thus health outcomes.

1.23 Lisa A. Cooper and Neil R. Powe. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient–Provider Racial, Ethnic, and Language Concordance. (July 2004). The Commonwealth Fund.

1.22 Center on an Aging Society, Cultural Competence in Health Care: Is it important for people with chronic conditions? Issue Brieifs and Data Profiles from the series Challenges for the 21st Century: Chronic and Disabling Conditions. Georgetown University. (February 2004)

1.21 Lake, Snell and Perry Associates Inc. Physician Perspectives on Communication Barriers Insights from Focus Groups with Physicians Who Treat Non-English Proficient and Limited English Proficient Patients (Executive Summary). Hablamos Juntos. Funded by the Robert Wood Johnson Foundation. (March 2004)

1.20 Lake, Snell and Perry Associates Inc. (March 2004) Physician Perspectives on Communication Barriers Insights from Focus Groups with Physicians Who Treat Non-English Proficient and Limited English Proficient Patients (Full Report). Hablamos Juntos. Funded by the Robert Wood Johnson Foundation. Physicians, we welcome your feedback related to this report.

1.19 Morbidity and Mortality Weekly Report.Health Disparities Experienced by Hispanics -- United States. (October 2004). Centers for Disease Control. 53(40);935-937

1.18 Bethell, Christina PhD, MPH, MBA, Kim Carter, MS, David Lansky, PhD, Brooke Latzke, Kris Gowen, PhD. (March 2003). Measuring and Interpreting Health Care Quality Across Culturally-Diverse Populations: A Focus on Consumer-Reported Indicators of Health Care Quality. FACCT-Foundation for Accountability.

1.17 Kaiser Commission on Medicaid and the Uninsured – Policy Brief. (August 2003). Disparities in Health Coverage, Access, and Quality: The Impact of Citizenship Status and Language on Low-Income Immigrants. This brief examines the roles of race/ethnicity, citizenship, and language on insurance coverage, access to care, and quality of care, with a focus on the low-income Latino population.

1.16 Jacobs, Elizabeth A., M.D., M.P.P., Agger-Gupta, Niels, Ph.D., Chen, Alice Hm, M.D., M.P.H., Piotrowski, Adam, and Eric J. Hardt, M.D. Language Barriers in Health Care Settings: An Annotated Bibliography of the Research Literature. The California Endowment. (August 2003)

1.15 Flores, Glenn, M.D., Laws, M. Barton, Ph.D., Mayo, Sandra J., Ed.M., Zuckerman, Barry M.D., Abreu, Milagros M.D., Medina, Leonardo M.D., and Eric J. Hardt, M.D. (January 2003). Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. American Academy of Pediatrics 111.1: 6-14.

1.14 Hasnain-Wynia Romana, Debra Pierce, and Mary A. Pittman (May 2004). Who, When, and How: The Current State of Race, Ethnicity, and Primary Language Data Collection in Hospitals. Health Research and Educational Trust - The Commonwealth Fund.

1.13 Ku, L. and T. Waidmann. How Race/Ethnicity, Immigration Status and Language Affect Health Insurance Coverage, Access to Care and Quality of Care Among the Low-Income Population. The Kaiser Commission on Medicaid and the Uninsured. (August 2003).

1.12 Suro, Roberto, and Jeffrey S. Passel. The Rise of the Second Generation: Changing Patterns in Hispanic Population Growth. Pew Hispanic Center. (October 2003).

1.11 Agency for Healthcare Research and Quality (AHRQ).National Healthcare Disparities Report. U.S. Department of Health and Human Services. (2003).

1.10 Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson, Editors. “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. The National Academies Press. (2003).

1.9 National Academy of Science Unequal Treatment. Unequal Health. What Data Tell Us About Health Gaps in California. Highlights findings from Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, published in 2002 by the Institute of Medicine (IOM).

1.8 Vandervort, E.B. and G.D. Melkus. “Linguistic Services in Ambulatory Clinics.” (October 2003). Journal of Transcultural Nursing 14.4: 358-366. This article describes a survey of language services offered by community health and the results. Although most of the clinics provided informal mechanisms of interpreter services, few directly addressed linguistic services as a component of culturally competent care.

1.7 Narayan, Mary Curry"The National Standards for Culturally and Linguistically Appropriate Services in Health Care” The Care Management Journals, Volume 3, Number 2, pages 77 – 83, (2002).   Describes 14 (CLAS) standards that were published in December 2000 by the Office of Minority Health.  It also suggests strategies for meeting the cultural and linguistic needs of home health care patients.

1.6 Andrulis, Dennis PhD, Nanette Goodman MA and Carol Pryor MPH. What A Difference An Interpreter Can Make, Health Care Experiences of Uninsured with Limited English Proficiency. The Access Project. (April 2002).

1.5 Hardt, Eric, M.D. Research in Medical Interpretation: Bibliography. The National Council on Interpreting in Health Care.(April 2001)

1.4 Howard, C.A., Andrade, S.J., and T. Byrd. The Ethical Dimensions Of Cultural Competence In Border Health Care Settings. Family & Community Health 23.4: 36-49. (January 2001). This article challenges the commonly understood definition of culture. It explores areas of concern related to cultural competency and medical ethics.

1.3 Wirthlin Worldwide. Hablamos Juntos: We Speak Together, Final Report. (2001). Research conducted for The Robert Wood Johnson Foundation on patient and provider perspectives on language barriers.

1.2 Wirthlin Worldwide. Hablamos Juntos - We Speak Together powpoint) (October/November 2001) Research conducted for The Robert Wood Johnson Foundation on patient and provider perspectives on language barriers.

1.1 Flores, Glenn, et al. (1998). Access Barriers to Health Care for Latino Children. Archive of Pediatric Adolescent Medicine. November. 152(11):1119-1125).

Population Change and Language Data


An easy-to-use tool, developed by the Social Science Data Analysis Network (SSDAN) at the University of Michigan, for investigating U.S. demographic trends by geography at different levels (states, metro areas, and counties) and to produce charts and exportable trend data from Ability to Speak English Among Those Speaking A Language Other Than English, 2000 Census data. http://www.censusscope.org.

Modern Language Map:

An easy-to-use map developed by the Modern Language Association to display the locations (state, county and zip code) and numbers of speakers of the thirty languages most commonly spoken in the United States. Also uses 2000 Census data. http://www.mla.org/

Growth in the Latino Population (1990 - 2000)

Click on your state for a full listing of county level population data.

New Jersey Pennsylvania Connecticut and Rhode Island New York Massachusetts Vermont and New Hampshire Maine Virginia West Virginia Maryland and Delaware Georgia Florida South Carolina North Carolina Louisiana Ohio Kentucky Indiana Tennessee Mississippi Alabama Michigan Wisconsin Arkansas Missouri Illinois Iowa Minnesota Oklahoma Kansas Nebraska South Dakota North Dakota Texas New Mexico Colorado Arizona Wyoming Utah Montana Idaho Nevada Alaska and Hawaii California Oregon Washington

2.8 Frey, William H. (October 2003). Metropolitan Magnets for International and Domestic Migrants. The Brookings Institution Center on Urban and Metropolitan Policy.

2.7 U.S. Census. (October 2003). Language Use and English-Speaking Ability: 2000. Census 2000 Brief.

2.6 Hablamos Juntos. (December 2001). Population Change for Hispanics from 1990 to 2000 by State - Fact sheet . The Robert Wood Johnson Foundation – Hablamos Juntos.

2.5 Medical School Graduates by race and ethnicity. StateHealthFacts.org has updated the race/ethnicity data for medical school graduates to 2004 and includes new data on Hispanic medical school graduates by state and region. Statehealthfacts.org, from the Henry J. Kaiser Family Foundation, provides free, up-to-date, and easy-to-use health and health policy data on all 50 states. Statehealthfacts.org has data on more than 500 health topics including Medicaid and SCHIP, Medicare, health coverage and the uninsured, health costs and budgets, providers and service use, minority health, women's health, and HIV/AIDS.

2.4 National Clearinghouse for English Language Acquisition (NCELA) (2000) Poster-English Language Learners & The U.S. Census 1990-2000. U.S. Department of Education – Office of English Language Acquisition, Language Enhancement and Academic Achievement for Limited English Proficient Students.

2.3 Markian Hawryluk, Lost in Translation: Ways to Afford Speaking Your Patients’ Languages, American Medical News (Dec. 2, 2002).

2.2 Audrey Singer and Jill H. Wilson, Polyglot Washington: Language Needs and Abilities in the Nation’s Capital, Brookings Institute (2004)

2.1 Kaiser Family Foundation. Key Facts Race, Ethnicity & Medical Care. The Henry J. Kaiser Family Foundation. A quick reference source on health, health coverage and health care use of minority Americans. (October 1999)

The Business Case for Language Access

3.7 The California Endowmnet. "Improving Access to Health Care for Limited English Proficient Health Care Consumers: Options For Federal Funding For Language Assistance Services"  To overcome language barriers assistance services, such as interpreters and translation of written health or medical materials, are essential. Through the attached Health …in Brief, V2:1 (April 2003)

Assessment of the Total Benefits and Costs of Implementing Executive Order No. 13166: Improving Access to Services for Persons with Limited English Proficiency, Report to Congress, Office of Management and Budget (March 14, 2002).

3.5 Bailit, Michael and Mary Beth Dyer Beyond Bankable Dollars: Establishing a Business Case for Improving Health Care. The Commonwealth Fund. (2004).

3.4 Brach C and Irene Fraser. Reducing Disparities through Culturally Competent Health Care: An Analysis of the Business Case. Quality Management in Health Care. No. 10 (4), 15-28. (2002).

3.3 Jacobs, Elizabeth A., M.D., M.P.P., Shepard, Donald S., Ph.D., M.P.P., Suaya, Jose A., M.D., M.B.A., and Esta-Lee Stone, M.S., OTR/L. Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health 94.5. (May 2004).

3.2 Rollins, Gina. Language Services in Public Hospitals: Limited Budget, Unlimited Support. National Association of Public Hospitals and Health Systems - The Safety Net 16.1: 22-25. (Spring 2002). Describes results of organization and community outreach for Rancho Los Amigos National Rehabilitation Center, an award-winning center.

3.1 Arizona Health FuturesStruggle to Communicate: Medical Interpretation in Arizona, (April 2004). Note: AHF is the policy and research arm of Phoenix-based St. Luke’s Health Initiatives. This document includes several pages on approaches to funding medical interpreting services.

Legal Requirements and Government Policy Related to Language Access

4.13 Miller, Tamara JD. "Effective Communication in Hospitals Initiative (LEP)" Power point U.S Department of Health and Human Services Office of Civil Rights (2008)

4.12 Snowden, L., Masland, M. & Guerrero, R. “Federal Civil Rights Policy and Mental Health Treatment Access for Persons With Limited English Proficiency” American Psychologist Vol. 62, No. 2, 109–117 (February–March 2007).

4.11 Marsha Lillie-Blanton and Caya B. Lewis. Policy Challenges and Opportunities in Closing the Racial/Ethnic Divide in Health Care. (March 2005).

4.10 Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (revised). U.S. Department of Health and Human Services. (August 2003).

4.9 Language Services Action Kit - Interpreter Services In Health Care Settings For People With Limited English Proficiency. The Access Project and the National Health Law Program (February 2004). An Action Kit for advocates and others working to ensure that people with limited English proficiency in their state get appropriate language assistance services in medical settings. (English and Spanish versions).

4.8 This video created by the Office for Civil Rights describes the legal principles guiding the provision of language services as stipulated by Title VI of the Civil Rights Act of 1964 and its prohibition against discrimination on the basis of national origin including limited English proficiency. The video explains the factors needed to provide meaningful access to programs and services by recipients of federal funding and portrays examples of language services.

4.7 Perkins, Jane, J.D., M.P.H. Ensuring Linguistic Access in Health Care Settings: An Overview of Current Legal Rights and Responsibilities. National Health Law Program-The Henry J. Kaiser Family Foundation – Kaiser Commission on Medicaid and the Uninsured. (August 2003).

4.6 Perkins, Jane, J.D., M.P.H., Youdelman, Mara, J.D., LL.M., and Doreena Wong. Ensuring Linguistic Access in Health Care Settings: Legal Rights & Responsibilities. (August 2003).

4.5 National Health Law Program. Assessment of State Laws, Regulations and Practices Affecting the Collection and Reporting of Racial and Ethnic Data by Health Insurers and Managed Care Plans: Preliminary Findings: Phase I: Executive Summary. National Health Law Program - US Department of Health and Human Services – Office of Minority Health. (2002).

4.4 Hablamos Juntos Workforce Investment Act. For the Robert Wood Johnson Foundation (November 2002). This report provides information on the Workforce Investment Act and examples of communities using these funds for health professions training. This is a potential resource for health interpreter training programs.

4.3 Federal Register. Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. U.S. Department of Justice, Vol. 67, No. 117:41455-41472. (June 18, 2002).

4.2 Dr. Dirk G. Schroeder, ScD, MPH. Emory University School of Public Health. (June 2002). Limited English Proficiency (LEP) Regulations: Implications and Guidance for U.S. Hospitals Serving Minority Populations. This paper provides a summary explanation of Federal Limited English Proficiency (LEP) regulations. It also describes recent lawsuits brought against hospitals based on LEP regulations and provides guidance on ways hospitals can ensure their compliance with LEP regulations.

4.1 U.S.Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: FINAL REPORT. U.S. Department of Health and Human Services. (March 2001)

Organizational Approaches to Language Access

5.18 National Public Health and Hospital Institute (NPHHI) Assuring Healthcare Equity:  A Healthcare Equity Blueprint.  A collaborative work of the National Public Health and Hospital Institute, the Institute for Healthcare Improvement, and the Disparities Solutions Center at Massachusetts General Hospital, September 2008.) 

5.17 America’s Health Insurance Plans. "Tools to Address Disparities in Health: Communications Resources to Close the Gap", (2006). Communications Resource to Close the Gap is a compendium of resources for health insurance plans, physicians, and health care organizations. This publication highlights tools, websites, and steps on how to incorporate culturally and linguistically appropriate messages into everyday communications with consumers.

5.16 U.S. Office of Minority Health."A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations, U.S. Department of Health and Human Services (2006). This guide is intended to help healthcare organizations implement effective language access services to meet the needs of their limited-English-proficient patients, and increase their access to health care.

5.15 Cindy Brach, Irene Fraser, and Kathy Paez. Crossing the Language Chasm. Health Affairs V24): 424-434. (March/April 2005):

5.14 National Association of State Workforce Agencies. Checklist for Developing a Limited English Proficiency (LEP) Plan. (January 2004).

5.13 Downing, Bruce T., Ph.D., and Cynthia E. Roat, MPH. Models For The Provision Of Language Access In Health Care Settings. Hablamos Juntos and The Robert Wood Johnson Foundation. (January 2002).

5.12 Annette Fuentes, Condition Critical: The Absence of Latinos Among Policymakers in New York City’s Voluntary Hospitals, Puerto Rican Legal Defense and Education Fund (December 2004). Note: Study funded in large part by the W.K. Kellogg Foundation.

5.11 Medical Leadership Council.Language Access Resources, 2002-2004 Proceedings of the The Medical Leadership Council on Language Acces. [Note: The Medical Leadership Council, founded by The California Endowment and convened annually by the California Academy of Family Physicians (CAFP), consists of some 28 organizations working to develop strategies for financing and delivering interpreter and translation services to LEP Californians.]

5.10 The Interagency Working Group on LEP. Language Assistance Self-Assessment and Planning Tool for Recipients of Federal Financial Assistance. Civil Rights Division, Department of Justice, Washington, DC.

5.9 Partida, Yolanda, MSW., DPA. Language Barriers to Health Care. Medical Journal, official publication of the Medical Society of Delaware.(2005)

5.8 National Health law Program Making Language Services a Reality 2005 Child Health Services Research Meeting. This PowerPoint Presentation (2005). Describes implemenation strategies for the provision of language services with informaiton on available reimbursement mechanisms, partnerships, and community based initiatives.

5.7 Mateo, Julio, and Elia V. Gallardo. Providing Health Care to Limited English Proficient (LEP) Patients: A Manual of Promising Practices. California Primary Care Association. (February 2004).

5.6 Cosmos Corporation. National Study of Culturally and Linguistically Appropriate Services in Managed Care Organizations, Fundeded by the Office of Minority Health, US Department of Health and Human Services (August, 2003)

5.5 Kathryn Paez and Margaret Gunter, Planning Culturally and Linguistically Appropriate Services: A Guide for Managed Care Plans, Centers for Medicaid and Medicare Services, HHS (February, 2003).

5.4 Language Access Advocacy Project California. Promising Practices in Healthcare. Powerpoint Presentation (2004).

5.3 Centers for Medicare and Medicaid.Providing Oral Linguistic Services: A Guide for Managed Care Plans. U.S Health and Humunan Services Department. (February, 2003).

5.2 Robert Putsch et al. Reflections on the CLAS Standards: Best Practices, Innovations and Horizons, Cross Cultural Health Care Program. (October, 2003)

5.1 Mara Youdelman, J.D., and Jane Perkins, J.D. Providing Language Services in Small Health Care Provider Settings: Examples from the Field. National Health Law funded by the Commonwealth Fund. (April 2005).

Interpreters and Interpreting

6.23 Hablamos Juntos. Language Testing Options 2008, Funded by The Robert Wood Johnson Foundation. An update to the 2002 report on language testing options with a sample of 35 language testing options (June 2008).

6.22 International Medical Interpreters Association. "Medical Interpreting Standards of Practice" (1995). Copyright 2007

6.21 Angelelli, Claudia. Medical Interpreting and Cross-cultural Communication. Cambridge University Press.(2004). Bringing together literature from social theory, social psychology, and linguistic anthropology, this first ever ethnographic study of a bilingual hospital explores the role of medical interpreters, drawing on data from over 300 medical encounters and interviews with health interpreters, their challenges, and how they characterize their role. Traditionally the interpreter has been viewed as a language conduit, with little power over the medical encounter or the relationship between patient and provider. This book presents an alternative view, considering the interpreter’s agency and contextualizing the practice within an institution that is part of a larger society.

6.20 Angelelli, Claudia. Revisiting the Interpreter’s Role, A study of conference, court, and medical interpreters in Canada, Mexico, and the United States. Benjamins Translation Library.(2004). The book reports on a study of the role that interpreters play in the various settings where they work, i.e. the courts, the hospitals, business meetings, international conferences, and schools. It presents interpreters' perceptions and beliefs about their work as well as statements of their behaviors about their practice as well as the administration and results of a survey administered across languages in Canada, Mexico and the United States.

6.19 Angelelli, Claudia. Interpretation Pedagogy: A Bridge Long Over Due. ATA Chronicle. (November/December 2000). Please note that this article is only available electronically if you are a member of the ATA.

6.18 Avery, Maria-Paz Beltrán, Ph.D., Chun, Ann, Downing, Bruce, Ph.D., Maynard, Marcia, R.I.D., and Karin Ruschke, M.A. Guide to Initial Assessment of Interpreter Qualifications. The National Council on Interpreting in Health Care: Working Papers Series. (April 2001).

6.17 Avery, Maria-Paz Beltrán, Ph.D. The Role of the Health Care Interpreter: An Evolving Dialogue. The National Council on Interpreting in Health Care: Working Paper Series. (April 2001).

6.16 Marjory Bancroft, MA. The Interpreter's World Tour: An Environmental Scan of Standards of Practice for Interpreters. The California Endowment, prepared for the National Council on Interpreting in Health Care. (March 2005).

6.15 Marjory Bancroft, MA. Standards of Practice for Interpreters. An Environmental Scan. National Council On Interpreting In Health Care Working Papers Series - The Commonwealth Fund and The California Endowment. (March 2004).

6.14 California Healthcare Interpreters Association.California Standards for Healthcare Interpreters, Ethical Principles, Protocols, and Guidance on Roles & Intervention. Funded by the California Endowment. (2002).

6.13 Hablamos Juntos. Interpreter Training Programs. Funded by the Robert Wood Johnson Foundation (October 2002) This report includes examples of medical interpreter training programs in a summary table and a narrative description with contact information and student cost.

6.12 Hablamos Juntos. Language Testing Options. Funded byt the Robert Wood Johnson Foundation (September 2002). A list of language proficiency and interpreting skill testing options provided for informational purposes only and not intended to imply any endorsement, recommendation or approval. The absence of health specific testing tools prompted Hablamos Juntos to pilot test a set of assessment tools in the demonstration sites.

6.11 Haffner, Linda, Karin Ruschke, MA, Shiva Bidar-Sielaff, MPH, Maria-Paz Avery, PhD; Bruce Downing, PhD; Carola Green; and Cynthia Roat, MPH. Guide To Interpreter Positioning In Health Care Settings. National Council on Interpreting in Health Care Working Papers Series. (November 2003).

6.10 Sharon M. Lee, Ph.D. and Clyde R. Pope, Ph.D., Patients Who Don’t Speak English: Improving Language Minorities’ Health Care with Professional Interpreters, Prepared for the Office of Minority Health, US Department of Health and Human Services (October, 2001).

Sharon M. Lee, Phd., Departmart of Sociology, Portland State University., A REVIEW OF LANGUAGE AND OTHER COMMUNICATION BARRIERS IN HEALTH CARE (April, 2003).

6.9 Massachusetts Department of Public Health Office. Best Practice Recommendations for Hospital-Based Interpreter Services. Commonwealth of Massachusetts, Executive Office of Health and Human Services, Massachusetts Department of Public Health Office of Minority Health. This reference guide is designed to assist acute care hospitals develop interpreter services consistent with the state.

6.8 Massachusetts Medical Interpreters Association. (MMIA) Code of Ethics. Found on International Interpreters Association website the new name for MMIA. http://www.imiaweb.org/standards/codeofethics.asp

6.7 Matthews, Clair, Johnson, Maree, Noble, Cathy, and A. Whelan/Kinklen. (January 2000). Bilingual Health Communicators: Role Delineation Issues. Australian Health Review 23.3: 104-112. This paper examines key features of the roles of interpreters and bilingual communication facilitators (scope of language, language proficiency, nature of communication/interaction, nature of the contact and relationship, client responsibilities, and relationship with other health care providers) and the differences in how bilingual health staff use language when providing care, and offers to extend the role of interpreter.

6.6 Monroe, Alicia D., and Taraneh Shirazian. Challenging Linguistic Barriers To Health Care: Students As Medical Interpreters. Academic Medicine 79.2: 118-122. (February 2004). Describes an interpreter aide program using bilingual undergraduate and medical students trained as medical interpreters implemented at Brown Medical School in 1997 to expand interpreter services to Spanish and Portuguese-speaking patients at Rhode Island Hospital.

6.5 National Council on Interpreting in Health Care. National Code of Ethics for Interpreters In Health Care. National Council On Interpreting In Health Care Working Papers Series for the Office for Minority Health, U.S Department of Health and Human Services. (July 2004).

6.4 National Standards of Practice for Interpreters in Health Care. Funded by the California Endowment. (September 2005) This publication explains the context in which the standards were developed, describes the process of development and suggests ways in which the standards can be used.

6.3 Paras, Melinda, Obiel A. Leyva M.P.H., Tim Berthold M.P.H., Raymond N. Otake J.D. Videoconferencing Medical Interpretation: The Results of Clinical Trials. Health Access Foundation. (April 2002).

6.2 Saint-Louis, Loretta, Ph.D., Friedman, Elisa, M.P.H., Chiasson, Emily, M.S.W., M.P.H., Quessa, Avlot, and Fernando Novaes. Testing New Technologies in Medical Interpreting. Cambridge Health Alliance: a Community of Caring. (June 2003). A study comparing four methods of providing interpreter services: traditional face-to-face, speakerphone, videoconferencing, and remote simultaneous interpreting equipment. Contrary to provider assumptions, patients are open to using technology for interpreting and, in many cases, preferred it.

6.1 Torres, Brunilda. Best Practice Recommendations for Hospital-Based Interpreter Services. Commonwealth of Massachusetts, Executive Office of Health and Human Services. (February 2004).

Translation and Quality Written Materials

7.18 Durban & Melby 2008. "Translation: Buying a Non-Commodity" - How translation standards can help buyers and sellers. Endorsed by the American Translator Association.

7.16 Andrew C. Bernard, MD, Audra Summers, RN, Jennifer Thomas, RN, Myrna Ray, MS, Anna Rockich, PharmD, Stephen Barnes, MD, Bernard Boulanger, MD, Paul Kearney, MD. Novel Spanish Translators for Acute Care Nurses and Physicians: Usefulness and Effect on Practitioners' Stress.(November 2005). This paper evaluates the effectiveness of a novel English-Spanish translator designed specifically to nurses and physicians. This report links communication barriers with stress levels among nurses and physicians caring for Spanish speaking patients.

7.15 This web repository is a compilation of over 300 health care documents that are translated into Los Angeles County’s ten threshold languages (Armenian, Chinese, English, Farsi, Khmer, Korean, Russian, Spanish, Tagalog, and Vietnamese). This serves to assist providers in better communicating with their LEP patients.

7.14 Cabrera, D.M., Morisky, D.E., and S. Chin. Development of a tuberculosis education booklet for Latino immigrant patients. Patient Education and Counseling 46.2: 117-124. (February 2002). Describes the stages used to develop a culturally sensitive TB education pamphlet for a low-literate Spanish-speaking immigrant population.

7.13 Colina, Sonia. Translation Teaching: From Research To The Classroom – A Handbook for Teachers. New York, San Francisco: McGraw Hill Second Language Professional Series. (2003).

7.12 Cornelio, Maria (2003).  ‘Health Literacy’ and the Medical Translator.  Apuntes, InTradES's quarterly publication, contains original articles, interviews, reference material and useful information for language professionals working with English and Spanish. http://spansig.org/Translation/apuntesdisplay.html

7.11 Cornelio, Maria Beware of the 'Bilingual Expert'.  ATA Chronicle (the journal of the American Translator Association).  August, Vol. 3 No. 8 (2003). 

7.10 Downing, Bruce T., Ph.D., and Laurence H. Bogoslaw, Ph.D. Translation as a Strategy for Effective Communication with Patients and Clients: A How-To Guide. Hablamos Juntos funded by the Robert Wood Johnson Foundation (April 2003)

7.9 Downing, Bruce T., Ph.D., and Laurence H. Bogoslaw, Ph.D. Effective Patient-Provider Communication Across Language Barriers: A Focus on Methods of Translation. Hablamos Juntos, funded by the Robert Wood Johnson Foundation. (February 2003).

7.8 Givaudan, Martha, Pick, Susan, De Venguer, Ma. Teresa T. and Ulises Xolocotzin. Development of an Instrument to Test the Cultural Adequacy of Health Related Written Material for Latinos in the USA. Hablamos Juntos, funded by the Robert Wood Johnson Foundation (October 2003).

7.7 Givaudan, Martha, Pick, Susan, De Venguer, Ma. Teresa T. and Ulises Xolocotzin. Bridging the Communication Gap: Provider to Patient Written Communication Across Language and Cultural Barriers. Hablamos Juntos, funded by The Robert Wood Johnson Foundation .(October 2002).

7.6 Jacobson, Holly, PhD. Ten Principles for Developing Effective Spanish Health Written Materials. University of North Texas Health Science Center, School of Public Health – Háblenos de Su Salud for Hablamos Juntos. (January 2004).

7.5 Jacobson, Holly E., Ph.D. Translation of the Health Brochure and Impact on the Target Reader: a Contrastive Analysis of the Structural and Pragmatic Features of Texts Translated into Spanish versus Texts Written Originally in Spanish. Ph.D. Dissertation. University of Arizona. (2003).

7.4 Kay, Martin. "Machine Translation." Linguistic Society of America website. (December 2004).

7.3 Koval, Alejandra Cultural Competency and Translation for Research. The ATA Chronicle. (August 2004).

7.2 Masset, H.A. Appropriateness of Hispanic Print Materials: A Content Analysis. Health Education Research 11.2: 231-242. (June 1996). This paper discusses the results of a content analysis of 26 national print breast cancer educational artifacts distributed to Hispanic women.

7.1 Moreno, Carmen; Matilde Alvarado; Hector Balcazar; Clare Lane; Hielen Newman, Gloria Ortiz, and Maxine Forrest. Heart Disease Education and Prevention Program Targeting Immigrant Latinos: Using Focus Group Responses to Develop Effective Interventions. Journal of Community Health, Vol. 22: No. 4. (December 1997).

Interpreter - Translator Training

8.9 Training programs and content curricula for translators:

8.8 Interpreter Training Resources. On this page you will find a brief introduction to some of the more useful texts published on simultaneous interpreting.

8.7 BA in Translation and Interpretation Studies (English/Spanish) at CSULB. Provides information on training programs and content curricula on Interpreting and Translation study.

8.6 Health Care Interpreter Training in the State of California. Roat, Cynthia E. M.P.H. for The California Endowment. (February 2003). Includes 21 training programs for the health care interpreters and analyze current trends in interpreter training in California.

8.5 Introduction to Interpreting: An Instructor's Manual. Laurie Swabey and Pam Sherwood Gabrielson. Program in Translation and Interpreting, University of Minnesota . A 45-hour generic interpreting course for bilingual speakers. Content, course materials, and resources ©1999

8.4 Worlds Apart: A Four-Part Series on Cross-Cultural Health Care. Grainger-Monsen, Maren M.D., and Julia Haslett. (2003) Funded by The Commonwealth Fund. A series of short films documenting the experiences of U.S. and foreign born minority patients in the U.S. health care system. The films capture communication challenges between patients and their doctors, tensions between modern medicine and cultural beliefs, and the ongoing burdens of racial and ethnic discrimination. Film clips and the study guide are available on this site.

8.3 Online Training for Doctors on Working with Interpreters. This program, developed by Cindy Roat and Dr. Liz Jacobs, confers up to 2½ 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 Cindy Roat.

8.2 Models for the Provision of Health Care Interpreter Training. National Council for Interpreters in Health Care. (February 2002).

8.1 Introduction To Health Care Interpreting Curriculum - Connecting Worlds, a statewide collaboration funded by The California Endowment, developed curriculum for teaching an introduction to health care interpreting. The curriculum includes an introduction to the theory, concepts, and skills associated with health care interpreting to teach an appreciation for the complexities of the roles and responsibilities of interpreters in the health care setting and the skills required to carry out those functions. A variety of teaching methods and materials, including lectures, videos, large group discussions, small group activities, role-plays, research and homework are recommended. The participant’s manual and workbook include simulated interpreting sessions and scenarios on challenging situations and to learn medical terminology (specifically anatomy and physiology and HIV/AIDS terminology). The Trainer Manual is only available for those taking a "train-the-trainer" session from one of the Connecting Worlds grantee organizations. 
Participant Manual | Participant Workbook


Ethics and Culture





Training Tools


Hablamos Juntos Training Programs

Hablamos Juntos demonstrations were introduced to the University of San Francisco Community College medical interpreter curriculum and encouraged to develop local training programs for health interpreters. Listed here are a diverse set of programs that came out of these efforts.

9.7 Medical Interpreter Certificate Program, Greenville Technical College, South Carolina
The Continuing Education program at Greenville Technical College offers college credentials in the form of a certificate. The students taking the CE courses are proficient in the Spanish language and come from professional backgrounds. The classes include topics on the role, ethics and skills of interpretation; bilingual medical terminology; common diseases; and examining challenging interpreting situations. MedVerse played a key role in developing this program and introduced practicing interpreters to help implement the curriculum. This program feeds into other four year programs.

9.6 Medical Interpreter Certificate Program – Central Community College, Grand Island, Nebraska. Central Community College, in rural Nebraska, worked with Central Nebraska-AHEC to offer to develop distance learning courses. Students use Internet for part of the training to earn a Medical Interpreter Certificate from where they live. The courses are integrated into other health professions training programs and designed to lead to an Applied Science Associate Degree. The program is working to make the curriculum available on DVD.

9.5 Language and International Health Program, Clemson University, South Carolina
Clemson University in Greenville, South Carolina, working with MedVerse, used the interpreter curriculum to complete an offering for a Bachelor of Science Degree in Language and International Health with two concentrations: Community Development and Health Administration. This program was approved by the state Council on Higher Education and will be offered on-going. The South Carolina on Languages (SCCOL) Spanish Placement Test for Languages is used to place students at the right entry point to continue second language development. Clemson University is also planning to offer a Certificate on Interpretation at the Graduate level.

9.4 Interpreter Care Interpreter Certificate Program – University of Tennessee Health Science Center. The Regional Medical Center, a public hospital in Memphis, Tennessee, partnered with the University of Tennessee Health Science Center to offer a Certificate of Continuing Education for a 14 week program to train health interpreters. This program recently enrolled its 3rd cohort of students.

9.3 Health Interpreting and Health Applied Linguistics ( HIHAL) Program, University of North Texas Health Sciences Center.The Master in Public Health HIHAL concentration is the only program in the United States preparing students seeking an M.P.H. degree to assume positions as professional health interpreters, linguistic researchers and leaders in the field of health applied linguistics. In the HIHAL students explore the interrelationship between language and health, and examine the complex relationship that exists between language and disease. The goal is to develop competencies in conducting language research in health settings, and offer extensive training as Spanish health interpreters, and, in some cases, as health writers and translators. This program, supported by local collaborating healthcare providers, combines interpreter training and research, and offers opportunities for thesis topics that are not readily available in other linguistics programs. Links to program: UNT Course Catalog | School of Public Health (UNT)

9.2 Healthcare Interpreter Training (HIT), Samford University, Birmingham, Alabama
Samford University offers Healthcare Interpreter Training (HIT), a 10 month certificate-level training program through Samford After Sundown, an adult education program. This program, the first in the region, was the result of a partnership with En Espanol. The first class enrolled 24 students, 22 graduated with certificates of completion in June 2005. En Espanol supported the first class with four full and 18 partial scholarships. Other students were sponsored by local health employers. Recruitment for a new class this Fall is currently underway.

9.1 Healthcare Interpreter Training (INTC), Community College of Rhode Island
The Community College of Rhode Island (CCRI) offers a three-semester medical interpreter-training program consisting of 15 units for three courses and a one-semester field practicum. The program is a result of a collaboration between Neighborhood Health Plan, CCRI and the Rhode Island Area Health Education Center (AHEC) which provides field placement opportunities for the students. Links to the program:
CCRI Course Catalog | NHPRI Special Programs | criAHEC


English Dictionary - Merriam-Webster English Dictionary Online.

English-French-Spanish Glossary of Food Items [Part 1 (A-F)] [Part 2 (G-Z)] . The Food and Agriculture Organization of the United Nations.

English-Spanish Dictionary of Health Related Terms. (July 2005). California Policy Research Center – California-Mexico Health Initiative, California Department of Health Services – California Office of Binational Border Health. The California Endowment.

Real Academia de la Lengua Espanola - Spanish Dictionary and Other Resources.

Ruschke, Karin, M.A., Haffner, Linda, Downing, Bruce, Ph.D., Avery, Maria-Paz Beltrán, Ph.D., and Marcia Maynard, R.I.D. (October 2001). The Terminology of Health Care Interpreting: A Glossary of Terms. The National Council on Interpreting in Health Care: Working Papers Series.

Virtual Health Library run by BIREME, the Latin American and Caribbean Health Sciences Information Center, a WHO/PAHO program. Includes a regional health information locator, access to journal articles, and a trilingual English-Portuguese-Spanish dictionary in the form of a health terminology search engine.

Professional Associations

The American Translators Association has chapters nationwide and maintains affiliations with many other local groups.

The California Healthcare Interpreting Association has compiled a list not only of health care interpreting associations, but also of other interpreting and translation associations nationwide.

Though Linguist List is not a professional organization, it offers a wealth of information on individual linguists as well as associations of linguists, linguistic research centers, and other topics. This information may be helpful for people looking to link up with linguists or other linguistic resources.

Massachusetts Medical Interpreters Association (MMIA)

Multicultural Association of Medical Interpreters of Central New York (MAMI)

National Council of Interpreters in Health Care (NCIHC)

Society of Medical Interpreters

Symbols Signage

10.8 Berger, Craig Universal Symbols In Health Care Workbook, Best Practices for Sign Systems. Hablamos Juntos and Society for Environmental Graphic Design funded the Robert Wood Johnson Foundation - (December 2005).

10.7 Jeremy J. Foster.Test methods for judged comprehensibility and for comprehension. ISO Bulletin. (December 2001). Manchester Metropolitan University. United Kingdom.

10.6 International Organization for Standardization (ISO). ISO in brief:International Standards for a Sustainable World (2005.

10.5 Massachusetts Department of Public Health. Poster Notice - Interpreter Availability at no cost. Contains the following message in 31 languages: - You have a right to a medical interpreter at no cost to you. Please point to your language. A medical interpreter will be called. Please wait. Can be downloaded free.

10.4 State of Florida. Poster Notice - Interpreter Availability at no cost. Contains the following message in 21 languages: Attention! If you do not speak English, or if you are deaf, hard of hearing, or sight impaired, YOU can have interpretive and translation services provided at no charge.Please ask for assistance. Can be downloaded free.

10.3 Symbol Usage In Health Care Settings for People with Limited English Proficiency Prepared by JRC Design in consultation with Hablamos Juntos and SEGD and others, this three-part paper, documents the conceptualization and development of universal symbols for health care.

Part One: Evaluation Of Use Of Symbol Graphics In Medical Settings. Bolek, Jim. JRC Design. Hablamos Juntos, funded by the Robert Wood Johnson Foundation (April 2003)  Provides a history of symbols use as well as an overview of the existing use of symbols in a healthcare setting.

Part Two: Implementation Recommendations. Bolek, Jim. JRC Design. Hablamos Juntos, funded by the Robert Wood Johnson Foundation (April 2003) Provides suggestions for the development and testing symbols for health care.

Part Three: Symbols Design Technical Report. Cowgill Jamie, Jim Bolek, Wendy T. Olmstead, Craig Berger, Phil Garvey. Hablamos Juntos and Society for Environmental Graphic Design. The Robert Wood Johnson Foundation (September 2005)  Summarizes the symbol development and testing process resulting in 28 health care symbols, contains the forms and resources used in testing.

Other Signage Resources


Dewar, Robert. “Design and evaluation of public information symbols.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.). 292. Taylor & Francis Inc. (1999).

Brugger, Christof. “Public information symbols: a comparison of ISO testing procedures.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.). 292. Taylor & Francis Inc. (1999).

Olmstead, Wendy T. “The usability of symbols for health care facilities: The effects of culture, gender and age.” Visual Information for everyday use. Harm J.G. Zwaga, et al (ed.).

Harm J. G. Zwaga, Theo Boersema and Henriette C. M. Hoonhout, editors. (1999) Visual Information for Everyday Use: Design and Research Perspectives. London: Taylor & Francis, 1999. 328 pp. (1999).


Environment of Care News : Using Universal Symbols: Improving Wayfinding Through Universal Signage Systems.(March 2007)

Haq, S. and Zimring, C. Just down the road a piece: The development of topological knowledge of building layouts. Environment and Behavior, Vol. 35 No. 1, pp 132-160. (January 2003).

O’Neill, M.J. Evaluation of a conceptual model of architectural legibility. Environment and Behavior, Vol. 23 No. 3, pp 259-284. (1991).

O’Neill, M.J. Effects of signage and floor plan configuration on wayfinding accuracy. Environment and Behavior, Vol. 23 No. 5, pp 553-574. (1991).

Lawton, C.A., Charleston, S.I., and Zieles, A.S. Individual and gender-related differences in indoor wayfinding. Environment and Behavior. Vol. 28, No. 2, pp 204-219. (1996).

Talbot, J.F., Kaplan, R., Kuo, F.E., and Kaplan, S. Factors that enhance effectiveness of visitor maps. Environment and Behavior, Vol. 25 No. 6, pp 743-760. (1993).

Related Websites and Organizations

Blogos - News and views on languages and technology

California Pan - Ethnic Health Network's Multicultural Health Web Portal

Cross Cultural Health Care Program

Diversity RX


Federal Government LEP Policy Guidance

Interpreter Training Resources

National Health Law Program

Center for Immigrant Health

news coverage

Media stories can be found in the Media Center.

Hablamos Juntos Grant Results

Hablamos Juntos: Improving Patient Provider Communication for Latinos - Grant Results
Hablamos Juntos was established as a national program of the Robert Wood Johnson Foundation (RWJF); the first national effort dedicated to language barriers. The first phase, with ten demonstrations in communities with new and fast-growing Latino populations ran from October 2001 through June 2006. The program focused on three key benchmarks:

  • Affordable models of language services
  • Useful health materials in languages other than English
  • Easy-to-understand signage within health facilities.

For a complete Grant Results report on the program, click here:

For more information about this grant award and Key Results, click here.