Abstract

Background

The importance of trained interpreters for ensuring adequate communication with limited English proficiency patients is well‐established. However, in many contexts, health professionals continue to rely on ad hoc interpreters, such as bilingual employees or patients' relatives to provide linguistic assistance. This is worrisome because these strategies have been shown to be associated with poor quality health care.

Methods

Objective: Examine attitudes and practices related to healthcare interpreting.

Design

Mailed, self‐administered questionnaire.

Setting and Participants

Convenience sample of medical and nursing department and service heads at the Geneva University Hospitals.

Outcome measures

Adequacy of attitudes and practices related to interpreter use.

Results

Ninety‐nine questionnaires were completed and returned (66% response rate). Between 43% and 86% of respondents relied mainly on patients' relatives and bilingual employees for linguistic assistance, depending on the language in question. Professional interpreter use varied according to language (from 5% to 39%) and seems to reflect the availability of bilingual staff members for the different languages. Professional interpreters appear to be used only in the absence of other available options, due to cost concerns and scheduling difficulties. This practice is further reinforced by the belief that ad hoc interpreters are “good enough” even while recognizing the quality differential between trained and untrained interpreters (91.2% of respondents rated bilingual staff as satisfactory or good, and 79.5% rated family/friends as satisfactory or good).

Conclusions

Simply making professional interpreter services available to healthcare professionals does not appear to guarantee their use for limited French proficiency (LFP) patients. Future efforts should focus on developing procedures for systematically identifying patients needing linguistic assistance, linguistic assistance strategies that are responsive to provider and institutional contexts and constraints, and institutional directives to ensure use of qualified interpreters for all medically important communication with LFP patients.

The challenges to health services posed by linguistic diversity have been extensively described in the literature. 1,2 A lack of attention to language barriers can lead to poor communication, a poor therapeutic alliance, suboptimal quality of care, and poor health outcomes. 3–6

The importance of professional interpreters for ensuring adequate communication with limited English‐speaking patients has been well‐established. 7,8 However, in many contexts, healthcare providers continue to rely on bilingual colleagues or the patients' family or friends to provide linguistic assistance. This is worrisome because these strategies have been shown to be associated with a number of problems related to poor quality communication and care and breaches of confidentiality. 9,10 The reliance on untrained interpreters may be simply a result of limited access to trained interpreters or may reflect a deeper resistance at both the individual and the institutional levels to call on professional interpreters when language barriers are encountered.

In Geneva, Switzerland, 43% of the population is foreign born and about 25% of the population speaks a language other than French at home. 11,12 Although there is presently no systematic collection of patients' French language proficiency in Swiss healthcare institutions, a survey conducted in 1999 found that about one fourth of patients visiting the primary care outpatient clinic at the Geneva University Hospitals needed linguistic assistance when communicating with providers. 13

A national survey conducted in 1999 of 244 public and private internal medicine and psychiatric clinics and hospitals in Switzerland (including those at the Geneva University Hospitals) found that only 17% of services had access to professional interpreters. 14 At that time, most services relied on patients' relatives (79%), bilingual health workers (75%), or nonmedical staff (43%) to provide linguistic assistance. (In Switzerland, a professional community interpreter is a paid interpreter who is hired and dispatched by an agency or charity, but the term does not currently imply any standardized screening, training, or supervision).

Since 1999, access to professional interpreters in Geneva has improved thanks to the Geneva Red Cross (GRC), which created an interpreter bank available to Geneva‐based social service and healthcare organizations. CRG interpreters receive minimal training (usually four 2‐hour workshops in which professional standards are communicated) and participate in several supervisory sessions per year.

The Geneva University Hospitals established a convention with the GRC in 1999, making the GRC interpreters available to all hospital staff needing linguistic assistance. The GRC provides the hospital with a regularly updated list of interpreters, which is accessible to staff via the hospital intranet system. Staff contact interpreters directly to make appointments, and interpreting is paid for by individual hospital departmental budgets.

This article reports on a survey conducted at the Geneva University Hospitals, a 2,000‐bed public hospital group. We describe current practices and perceptions regarding healthcare interpreting, discuss how practices have evolved since 1999, and analyze the ongoing challenges to ensuring access to and use of professional interpreter services for limited French proficiency (LPF) patients.

Methods

The data reported on here were collected as part of a larger research project investigating community interpreting and intercultural mediation in public institutions in Geneva and Basel. It is one of the 35 projects supported by National Research Programme 51 on social integration and social exclusion. 15

We developed a self‐administered questionnaire. The questions were pretested in both Geneva and Basel, but were not validated. The questionnaire was mailed to all head doctors and all head nurses of each of the 70 clinical services in 11 clinical departments, as well as to all 11 department heads (total = 151). In a cover letter explaining the purpose of the study, these individuals were asked to either answer the questionnaire themselves or to ask a colleague of the same profession in their service to answer it. Only one mailing was conducted due to time constraints, but a 66% response rate was considered good compared to other surveys of health personnel. Data collection was carried out between March and November 2004. No reminders were sent.

The questionnaire asked about respondents' sociodemographic and professional characteristics, characteristics of the clinical service in which they worked, their use of different linguistic assistance strategies in their current clinical service, perceptions of the quality of interpretation provided by different types of interpreters, and their opinions regarding the impact of interpreter services on their work and on immigrant patients' integration into Swiss society (see Table 1 for a description of survey questions and response categories).

Table 1

Survey questions

In which clinical service do you currently work? Open‐ended question 
What is your current function at the hospital? Open‐ended question 
Please estimate the proportion of immigrant patients in your service in 2003 Open‐ended question 
Please estimate the proportion of patients with limited French proficiency in your service in 2003 Open‐ended question 
What is your mother tongue? List of languages; more than one response possible 
Were you born abroad? Yes/No 
Was one or more of your parents born abroad? Yes/No 
Are you ever asked to provide interpretation? Yes/No 
How often do you use interpreters (of any kind)? Never, daily, once a week, once a month, a few times per year, I don't know 
For about how many years have you been using interpreters (of any kind) in your work? No. years 
For about how many years has your institution been using interpreters (of any kind)? No. years 
Which of the following interpreting strategies do you use the most often, for each of the following languages? • Professional interpreters 
• Untrained volunteers 
• Bilingual employees (clinical and nonclinical) 
• Patients' relatives/friends 
• I am my own interpreter (I speak this language) 
How do you rate the general quality of interpretation provided by the following persons? Poor, satisfactory, good, excellent, I don't know 
• Professional interpreters 1 (false) to 4 (perfectly true) 
• Untrained volunteers 
• Bilingual employees (clinical and nonclinical) 
• Patients' relatives/friends 
Rate the following statements: 
 With the use of interpreters …. 
• Immigrants' autonomy is strengthened 
• Immigrants are better informed 
• Immigrants are not encouraged to learn the local language 
• Immigrants become dependent on interpreters 
• Immigrants are better informed about their rights 
In which clinical service do you currently work? Open‐ended question 
What is your current function at the hospital? Open‐ended question 
Please estimate the proportion of immigrant patients in your service in 2003 Open‐ended question 
Please estimate the proportion of patients with limited French proficiency in your service in 2003 Open‐ended question 
What is your mother tongue? List of languages; more than one response possible 
Were you born abroad? Yes/No 
Was one or more of your parents born abroad? Yes/No 
Are you ever asked to provide interpretation? Yes/No 
How often do you use interpreters (of any kind)? Never, daily, once a week, once a month, a few times per year, I don't know 
For about how many years have you been using interpreters (of any kind) in your work? No. years 
For about how many years has your institution been using interpreters (of any kind)? No. years 
Which of the following interpreting strategies do you use the most often, for each of the following languages? • Professional interpreters 
• Untrained volunteers 
• Bilingual employees (clinical and nonclinical) 
• Patients' relatives/friends 
• I am my own interpreter (I speak this language) 
How do you rate the general quality of interpretation provided by the following persons? Poor, satisfactory, good, excellent, I don't know 
• Professional interpreters 1 (false) to 4 (perfectly true) 
• Untrained volunteers 
• Bilingual employees (clinical and nonclinical) 
• Patients' relatives/friends 
Rate the following statements: 
 With the use of interpreters …. 
• Immigrants' autonomy is strengthened 
• Immigrants are better informed 
• Immigrants are not encouraged to learn the local language 
• Immigrants become dependent on interpreters 
• Immigrants are better informed about their rights 

In our study, the term “non‐Swiss patients” refers to any category of foreigner (immigrants, asylum seekers, refugees, foreign workers, etc.) living in Switzerland but without a Swiss passport. We use the term “professional interpreter” to refer to agency interpreters (the primary source of professional interpreters in Switzerland), as contrasted with ad hoc interpreters. However, it is important to note that there are no standardized requirements for agency interpreters and their training and experience vary widely both between and within interpreter agencies. Finally, we defined three categories of ad hoc interpreters: bilingual employees, untrained volunteer interpreters, and patients' relatives or friends.

Respondents were asked to indicate which categories of interpreters they used for each of a list of patients' primary language spoken at home. Since some respondents chose more than one option for a single language, and not all responded for all languages, the total Ns for each language vary (Table 2).

Table 2

Association of interpreter category with patients primary language spoken at home

Language Professional interpreters (%) Untrained volunteers (%) Bilingual employees (%) Patients' relatives/friends (%) Clinician speaks patient's language (%) Chi‐square p Value 
Tamil (N = 65) 39 18 37 43.6 <0.001 
Albanian (N = 99) 37 15 19 28 67.3 <0.001 
Bosnian (N = 91) 37 15 21 25 74.6 <0.001 
Serbian (N = 101) 36 15 22 27 67.9 <0.001 
Croatian (N = 101) 35 14 26 25 71.9 <0.001 
Turkish (N = 91) 28 12 30 30 61.5 <0.001 
Arabic (N = 100) 23 44 24 125.3 <0.001 
Portuguese (N = 98) 70 16 207.3 <0.001 
Spanish (N = 107) 55 16 21 138.8 <0.001 
Language Professional interpreters (%) Untrained volunteers (%) Bilingual employees (%) Patients' relatives/friends (%) Clinician speaks patient's language (%) Chi‐square p Value 
Tamil (N = 65) 39 18 37 43.6 <0.001 
Albanian (N = 99) 37 15 19 28 67.3 <0.001 
Bosnian (N = 91) 37 15 21 25 74.6 <0.001 
Serbian (N = 101) 36 15 22 27 67.9 <0.001 
Croatian (N = 101) 35 14 26 25 71.9 <0.001 
Turkish (N = 91) 28 12 30 30 61.5 <0.001 
Arabic (N = 100) 23 44 24 125.3 <0.001 
Portuguese (N = 98) 70 16 207.3 <0.001 
Spanish (N = 107) 55 16 21 138.8 <0.001 

Descriptive analyses (frequency distributions and cross‐tabulations) including nonparametric chi‐square tests were carried out using SPSS 14.0.

Results

Respondent Characteristics

Ninety‐nine questionnaires were completed and returned, representing a 66% response rate. Respondents included 48 physicians and 47 nurses. Four respondents provided no information about their professional status. All 11 medical departments were represented in the final sample. No data are available on non‐respondents.

French was the mother tongue of 81 respondents (82%); 18 spoke a non‐French mother tongue. Many of them spoke other languages fluently: 70 spoke English fluently, 29 German, 27 Spanish, 21 Italian, 4 Portuguese, 3 Arabic, and 2 Serbo‐Croatian. Forty‐four respondents (44%) had previously provided medical interpretation.

Service Characteristics

The mean estimated percentage of non‐Swiss patients was 27% but varied widely (SD 23.8). The mean estimated percentage of LFP was 15% (SD 13.4). Thirty‐one respondents (31%) said that they were aware of the existence of written guidelines regarding the use of interpreter services.

Use and Perceptions of Different Types of Interpreters

The majority of respondents reported using interpreters (either professional or ad hoc) only a few times a year (66%). Eighteen percent said that they used interpreters about once a month and 10% reported never using an interpreter.

The strategies used most frequently to overcome language barriers varied according to the language in question (Table 2).

For Portuguese and Spanish, over half of the respondents used bilingual employees most often, while only 5% to 6% used professional interpreters most often. In contrast, over a third of the respondents used professional interpreters most often for Tamil, Albanian, Bosnian Serbian, and Croatian. Between 2 and 18% of respondents used untrained volunteer interpreters most often. At least a quarter of the respondents relied on patients' relatives and friends to interpret for all but Portuguese and Spanish.

Respondents were asked to rate the quality of interpreting provided by the different types of interpreters (Table 3). Seventy‐three percent thought that professional interpreters provided good (32%) or excellent interpreting (41%), while 64% thought that hospital employees provided good (60%) or excellent interpreting (3%). The quality of patients' relatives and friends' interpreting was rated lower: 13% thought their interpreting was poor and only 27% thought family members provided good to excellent interpreting. Nonetheless, 57% said patient relatives' interpreting was “satisfactory.” The quality of volunteer interpreters' interpreting was rated as satisfactory by 6% of respondents, good by 37%, and excellent by 7%. These data should be considered with some caution, however, because respondents had relatively low frequency of contact with interpreters. Also, we have no information on the complexity of the exchanges in which respondents used interpreters, which can influence interpreter quality.

Table 3

Assessment of quality of different types of interpreters in health institutions

 Professional interpreters (n = 99) Untrained volunteers (n = 99) Bilingual staff (n = 99) Patients' relatives/friends (n = 99) 
Poor (%) 1.4 2.0 12.5 
Satisfactory (%) 6.1 14.3 30.8 56.8 
Good (%) 31.7 37.1 60.4 22.7 
Excellent (%) 41.5 7.1 3.3 4.5 
Do not know (%) 20.7 40 3.3 3.4 
Chi‐square 22.7 43.3 119.5 85.1 
p Value <0.001 <0.001 <0.001 <0.001 
 Professional interpreters (n = 99) Untrained volunteers (n = 99) Bilingual staff (n = 99) Patients' relatives/friends (n = 99) 
Poor (%) 1.4 2.0 12.5 
Satisfactory (%) 6.1 14.3 30.8 56.8 
Good (%) 31.7 37.1 60.4 22.7 
Excellent (%) 41.5 7.1 3.3 4.5 
Do not know (%) 20.7 40 3.3 3.4 
Chi‐square 22.7 43.3 119.5 85.1 
p Value <0.001 <0.001 <0.001 <0.001 

Despite the relatively infrequent use of professional interpreters, respondents had a positive attitude regarding the impact of these interpreters on healthcare quality and on immigrants' social integration. A total of 100% of respondents felt that patient–provider communication was improved when professional interpreters were used and 76% thought they helped reduce conflicts with patients. Ninety percent thought that professional interpreters helped them to better understand their patients, and 94% felt they helped them to more effectively communicate instructions to patients.

A majority of respondents also felt that professional interpreters helped immigrants to integrate into society by increasing patients' autonomy (80%) and by ensuring that immigrants are generally well informed (80%) and know their rights (86%). However, 20% thought that immigrants could become too dependant on interpreters and 6% thought that the use of interpreters prevented patients from learning the local language.

Factors Affecting Respondents' Use of Interpreters

Twenty‐five respondents said that they could not call on a professional interpreter whenever they desired. Reasons given for this were the need to exhaust other strategies before calling a professional interpreter due to budgetary constraints (n = 11) and problems of interpreter availability, eg, on short notice or for emergencies (n = 14).

Discussion

Our study showed that most respondents use interpreters to communicate with their limited French proficient (LFP) patients. However, we found that respondents are generally underusing professional interpreters and overusing ad hoc interpreters. In addition, certain language groups (Turkish, Arabic, Portuguese and Spanish) are at increased risk of ad hoc interpreter use.

The choice to use professional versus ad hoc interpreters seems to be influenced by three main factors: availability of bilingual staff, perceptions of interpreting quality, and cost concerns. 16

Our data suggest that professional interpreters are called in only after other strategies have failed, due to cost concerns and practical issues. One major problem is that no systematic collection of patient language data currently exists at the Geneva University Hospitals, making it difficult to plan efficiently for professional interpreter use and to monitor healthcare quality for LFP patients. Anecdotal information from our work in the hospital also suggests that clinicians in some departments are more comfortable calling on a bilingual staff member than organizing an appointment with a professional interpreter. This is especially true in departments that do not have a strong “service culture” emphasizing the importance of professional linguistic assistance for health care quality and safety. In these departments, clinical staff are less familiar with how to organize an appointment with an interpreter, and less comfortable working with a non‐staff interpreter. In order to address this problem, language services need to be integrated into organisational routines. Although this has been successfully accomplished in a number of hospitals in the USA, several studies point to the challenges involved in implementing such institutional changes 3,17,18 .

Another strategy that has been implemented in a number of settings is to identify bilingual healthcare staff who can officially (rather than informally) double as interpreters. This strategy can be easily integrated into existing clinical routines, and has fewer visible costs than professional agency interpreters, such as those used in Geneva. However, there are invisible costs involved with removing a staff member from one role to fulfill another 16 and to ensure the quality of their interpreting it is important to train and assess bilingual staff just as for professional interpreters. 20–22

Indirect pressures from hospital administration to minimize the use of professional interpreters and give priority to no‐cost solutions such as family members and bilingual staff are a further disincentive to using professional interpreters. Such messages may in part explain why our respondents seem to think that ad hoc interpreters are “good enough”. 91.2% of respondents thought that interpreting provided by bilingual staff was satisfactory or good, and 79.5% thought that interpreting provided by family/friends was satisfactory or good. A lack of awareness of the impact of language barriers on quality of care and of the dangers of ad hoc interpreting may also lead to uncritical acceptance of lower quality interpreting. In addition, the heterogeneous training and experience of professional interpreters in our setting, and the lack of clear standards for recruitment and evaluation, means that professional interpreters may not always provide higher quality interpreting than ad hoc interpreters. The fact that 58.5% of our respondents rated interpreting by professional interpreters as less than excellent may be a reflection of the variable interpreting quality in our setting.

Our study has a number of limitations. First, it was carried out in only one hospital system in one Swiss city, and therefore results may not be generalizable to other settings. Second, we had a 34% non‐response rate, with no data on non‐responders, and therefore cannot say to what degree our results reflect non‐response bias. Our questionnaire items were not validated, and our data did not allow for multivariable analyses of factors associated with use of professional interpreters. Finally, our data did not allow us to examine the reasons that some services continue to use children as ad‐hoc interpreters, a worrisome practice identified in a number of studies 2,23,24 .

Despite these study weaknesses, our results suggests that simply making professional interpreter services available to health care professionals is not enough to ensure their systematic use for LFP patients.

In the United States, the existence of Federal requirements related to the provision of culturally and linguistically appropriate services has been an important catalyst for change in this area. 25 A set of “National Standards on Culturally and Linguistically Appropriate Services” was developed by the Office of Minority Health to help hospitals ensure quality care for diverse populations (OMH, 2001), and the Joint Commission on Accreditation of Healthcare Organizations (which establishes quality criteria for hospitals and evaluates their performance) has developed a series of hospital requirements related to the provision of culturally and linguistically appropriate health care. 26

In Europe, the European Commission's “Migrant Friendly Hospitals” project has developed a series of 11 recommendations for ensuring quality health care for diverse populations. 27 In the Netherlands, the Ministry of Health has forbidden the use of nonprofessional interpreters, and healthcare workers who do so can be sued. 28 In Switzerland, at a recent meeting of the Swiss Network of Health Promoting Hospitals, 29,30 a newly developed set of standards was announced for the provision of linguistically and culturally appropriate care.

Each of these efforts emphasizes the importance of setting standards for linguistically and culturally appropriate care and developing explicit institution‐wide policies and procedures for achieving these standards. Some argue that investment in national and even international‐level solutions will be needed to ensure broad‐ranging access to linguistic services. 31 As populations become increasingly diverse, priority needs to be given to developing procedures for systematically identifying patients needing linguistic assistance, linguistic assistance strategies that respond to provider and institutional contexts and constraints, and institutional directives that ensure use of qualified interpreters for all medically important communication with patients who do not speak the local language. Only then will hospitals be able to ensure high quality, patient‐centered care for all patients.

The survey was funded by the National Research Programme NRP 51, entitled “Social Integration and Social Exclusion” (Swiss National Science Foundation), grant no. 405140‐69224 for project titled “Intercultural mediation: Does it contribute to inclusion? Comparing policies and practices in the sectors of health, education, social, and legal services.”

Declaration of interests

The authors state that they have no conflicts of interest.

References

1
Smedley
BD
Stith
AY
Nelson
AR.
Unequal treatment. Confronting racial and ethnic disparities in health care
 . Washington:
The National Academies Press
,
2003
.
2
Flores
G.
The impact of medical interpreter services on the quality of health care: a systematic review
.
Med Care Res Rev
 
2005
;
62
:
255
299
.
3
Divi
C
Koss
RG
Schmaltz
SP
Loeb
JM.
Language proficiency and adverse events in US hospitals: a pilot study
.
Int J Qual Health Care
 
2007
;
19
:
60
67
.
4
Ku
L
Flores
G.
Pay now or pay later: providing interpreter services in health care
.
Health Aff (Project Hope)
 
2005
;
24
:
435
444
.
5
Yeo
S.
Language barriers and access to care
.
Annu Rev Nurs Res
 
2004
;
22
:
59
73
.
6
Bischoff
A
Bovier
P
Rrustemi
I
, et al.
Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral rates
.
Soc Sci Med (1982)
 
2003
;
57
:
503
512
.
7
Karliner
LS
Jacobs
EA
Chen
AH
Mutha
S.
Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature
.
Health Serv Res
 
2007
;
42
:
727
754
.
8
Loutan
L.
The importance of interpreters to insure quality of care for migrants
.
Soz Praventivmed
 
1999
;
44
:
245
247
.
9
Flores
G
Laws
MB
Mayo
SJ
, et al.
Errors in medical interpretation and their potential clinical consequences in pediatric encounters
.
Pediatrics
 
2003
;
111
:
6
14
.
10
Elderkin‐Thompson
V
Silver
RC
Waitzkin
H.
When nurses double as interpreters: a study of Spanish‐speaking patients in a US primary care setting
.
Soc Sci Med
 
2001
;
52
:
1343
1358
.
11
OCSTAT
.
Bilan et état de la population du canton de Genève en 2006. Données statistiques n 2007/2, Genève
, Mars 2007. Geneva:
OCSTAT (Office cantonal de statistique)
, 2007.
12
OCSTAT
.
Portrait statistique des étrangers vivant à Genève
.
Données statistiques no. 2007/37
. Genève, September 2006. Geneva:
OCSTAT (Office cantonal de statistique)
, 2007.
13
Bischoff
A
Tonnerre
C
Loutan
L
Stalder
H.
Language difficulties in an outpatient clinic in Switzerland
.
Soz Praventivmed
 
1999
;
44
:
283
287
.
14
Bischoff
A
Tonnerre
C
Eytan
A
, et al.
Addressing language barriers to health care, a survey of medical services in Switzerland
.
Soz Praventivmed
 
1999
;
44
:
248
256
.
15
Dahinden
D
Bischoff
A.
Interkulturelle Mediation: welche Form der Integration?
Bulletin NFP
 
51
:
2005
; 2:
9
10
.
16
Drennan
G.
Counting the cost of language services in psychiatry
.
S Afr Med J
 
1996
;
86
:
343
345
.
17
Greenhalgh
T
Voisey
C
Robb
N.
Interpreted consultations as ‘business as usual’? An analysis of organisational routines in general practices
.
Sociol Health Illn
 
2007
;
29
:
931
954
.
18
Regenstein
M.
Measuring and improving the quality of hospital language services: insights from the Speaking Together collaborative
.
J Gen Intern Med.
  2007 Nov;
22
Suppl 2
:
356
9
.
19
Bischoff
A
Steinauer
R.
Nursing interpreters? Interpreting nurses?
Pflege
 . 2007 Dec;
20(6)
:
343
51
.
20
Matthews
C
Johnson
M
Noble
C
Klinken
A.
Bilingual health communicators: role delineation issues
.
Aust Health Rev
 .
2000
;
23(3)
:
104
12
.
21
Mátir
J
Willis
D.
Using bilingual staff as interpreters
.
Family Practice Management
 .
2004
;
11
:
34
6
.
22
Moreno
MR
Otero‐Sabogal
R
Newman
J.
Assessing dual‐role staff‐interpreter linguistic competency in an integrated healthcare system
.
J Gen Intern Med.
  2007 Nov;
22
Suppl 2
:
331
5
.
23
Flores
G.
Language barriers to health care in the United States
.
The New England journal of medicine
 . 2006 Jul 20;
355(3)
:
229
31
.
24
Lee
KC
Winickoff
JP
Kim
MK
Campbell
EG
Betancourt
JR
Park
ER
, et al.
Resident Physicians' Use of Professional and Nonprofessional Interpreters: A National Survey
.
JAMA
 . 2006 September 6, 2006;
296(9)
:
1050
3
.
25
Chen
AH
Youdelman
MK
Brooks
J.
The legal framework for language access in healthcare settings: Title VI and beyond
.
J Gen Intern Med.
  2007 Nov;
22
Suppl 2
:
362
7
.
26
Joint Commission
.
Hospitals, Language and Culture, a snapshot of the Nation
.
2008
. Available at: http://www.jointcommission.org/PatientSafety/HLC/. (Accessed 2008 Feb 7)
27
LBISM
.
The Amsterdam Declaration: Towards Migrant‐Friendly Hospitals in an ethno‐culturally diverse Europe
. Vienna: Ludwig Boltzmann Institute for the Sociology of Health and Medicine (LBISHM) at the University of Vienna, Faculty of the Social Sciences, WHO Collaborating Centre for Health Promotion in Hospitals and Health Care,
2004
. Available at: http://www.mfh-eu.net/conf/downloads/AmsterdamDeclaration2004.pdf. (Accessed 2008 Oct 10)
28
Dickover
DW
Bot
H.
Patterns of communication through interpreters
.
J Gen Intern Med.
  2007 Jun;
22(6)
:
895
; author reply 6.
29
HPH‐MFH
.
Diversité et égalité des chances: quels critères pour les hôpitaux migrant friendly?
2007
cited 2008‐01‐18. Available at: http://www.healthhospitals.ch/franz/. Accessed 2008 Jan 18)
30
Saladin
P
Bühlmann
R
Dahinden
D
Gall Azmat
R
Ebner
G
Wohnhas
J.
Diversity and equality of opportunity. Fundamentals for effective action in the microcosm of the health care institution
. Bern: FOPH ‐ Federal Office of Public Health, in collaboration with H+ Swiss Hospital Association
2007
.
31
Partida
Y.
Addressing language barriers: building response capacity for a changing nation
.
J Gen Intern Med.
  2007 Nov;
22
Suppl 2
:
347
9
.

Author notes

Upon request by the authors, corrections have been made after online publication dated 06 May 2009.