National Center for Cultural Competence
Georgetown University Center for Child and Human Development
University Center for Excellence in Developmental Disabilities
Curricula Enhancement Module Series
Division of Research, Training and Education
Maternal and Child Health Bureau
Health Resources and Services Administration (HRSA)
U.S. Department of Health and Human Services (DHHS)
Process of Inquiry—Communicating in a Multicultural Environment Module
Table of Contents
Section A. Overview and Purpose of Module Series
Section B. Cultural and Linguistic Competence: Rationale, Conceptual Frameworks, and
Values
Section C. Process of Inquiry—Communicating in a Multicultural Environment Module
Introduction, Purpose, and Rationale
Key Content Areas With Process Activities
Section D. Teaching Tools, Strategies, and Resources
Areas of Awareness, Knowledge, and Skills
Vignettes
Teaching Tools
Resources for the Process of Inquiry Module
Resources for the Module Series
Appendix
References
Acknowledgments
About the NCCC
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Section C.
Process of Inquiry—Communicating in a Multicultural Environment
Introduction, Purpose, and Rationale
Health care, public health, and mental health care systems have the responsibility to both
receive and convey a complex array of information to a myriad of audiences for a broad
variety of purposes. The following is a selected listing of such audiences and purposes in
which the dynamics of communication are cross-cutting.
Audience
Purpose


provider-patient and/or family level

organizational level

community level

population-based level


local, county, state, and national levels


international level

build trusting relationships with individuals,
families, and communities for improved health
and well-being
craft and deliver health and wellness promotion
messages to individuals, families, and
communities
report on epidemiological trends and disease or
illness burden
provide general and/or population-specific risk
reduction, screening, and early intervention
services and information
Section C: (1) presents a rationale of the critical importance of communication in health
care, public health, and mental health care systems, particularly in light of the
multicultural and multilingual groups that compose the U.S. population today;
(2) explores the concept of the process of inquiry and its implications for communication
in a multicultural environment; (3) connects the concept of process of inquiry to policy,
practices, and procedures at the individual and organization levels; and (4) weaves
activities through the key content to enhance knowledge application. The content of this
module is designed for full integration into the curricula of training programs in health,
mental health, and public health as they prepare the current and future leaders in these
systems.
Key Content Areas in the Process of Inquiry—Communicating in a Multicultural
Environment
I.
The Language-Culture Link
II. Communication, Culture, Health, and Mental Health Care
III. Communication and Quality of Care
IV. Process of Inquiry: Attitudes and Knowledge
V. Process of Inquiry: Skill Building and Tools
VI. Applying the Process of Inquiry to Communities
VII. Communicating With Limited English Speakers in Health and
Mental Health Care Settings
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I. The Language-Culture Link
For the purposes of this module, the following definitions are offered from Owens
(2005):
Communication: The process participants use to exchange information and ideas, needs,
and desires. The process is an active one that involves encoding, transmitting, and
decoding the intended message (p. 11).
Language: A socially shared code or conventional system for representing concepts
through the use of arbitrary symbols and rule-governed combination of those symbols (p.
7).
Speech: A verbal means of transmission (p. 6).
World Knowledge: An individual’s autobiographical and experiential understanding and
memory of particular events. This knowledge reflects not only the individual but the
cultural interpretation placed on knowledge (p. 23).
Learning culture, learning language
Language and culture, in many ways, are inextricably linked. Culture is encoded in
language through forms of expression, communication preferences and the way words are
used (e.g., “The door is closed.” “The door closed.”). Values, beliefs, and attitudes and a
broad array of nuances are enmeshed in words and symbols, forming the base of
knowledge and a system for communicating within every culture. The ability to use
words to represent ideas, concepts, etc. allows people to build world knowledge and an
effective system to communicate. Using language, one can express thoughts, feelings
and preferences and comprehend others.
World knowledge enables people to communicate and to live, work, play, learn, and
worship together. Words or symbols in themselves do not have meaning, only the
potential for meaning. Children learn to associate the clear liquid handed to them in a cup
with the word “water” or “agua,” depending on what they are taught by the people around
them.
Language, a complex and dynamic system of conventional symbols that are used for
thought and communication (Committee on Language, 1983), is learned in a social
context, shaped by the customs and practices of those around us. For example, Central
Alaskan Yupik Eskimo language has about a dozen words for referring to snow and to
related natural phenomena, events, or behavior. Language and the words we use are also
acquired through educational pursuits. An example from the Institute of Medicine (IOM)
report, 2002, cites Long, Scrimshaw, and Hernandez, 1992, in which a word used by a
neurologist, “trauma,” to mean “injury” was understood as “emotional shock” by the
Mexican mother of a child with seizure disorders. This is a clear illustration that the
meaning attached to words can be different as a result of technical knowledge.
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Language is socially constructed. Shared patterns and codes of behavior form a group
culture; a way of being. However, culture is porous and socially constructed – learned
from others, shaped by events and shared experiences, conventions for social interaction
and the environment. To have culture is indeed human nature, but no specific culture is
human nature. Different words for concepts such as “water” or “chair” are easily
translatable across cultures because there are objects to reference; concepts such as
“mother love,” “death,” and “sickness” are another thing entirely, because each of these
is packed with cultural connotations that are unique, abstract, and difficult to translate.
Much of culture, in fact the most important part, exists in people’s minds and is invisible!
The relationship between culture and language is dynamic. Culture influences one’s
worldview and the interpretation of the realities one experiences. New words are created
from new realities. Similarly, existing words and expressions acquire new meanings: five
years ago “9/11” was just a way of writing a date. Today this term has significant,
different connotations for people, both in the United States and throughout the world.
Because culture and experience are not static, language is not static; it is constantly
evolving. The automatic teller machine (ATM) is an example of how the idea of banking
began to change and how the mental map of “bank” was redrawn; the banking hours and
other related activities were also redefined.1 As the use of ATMs took hold in the 1970s,
early users of ATMs learned a new concept for banking. As a result, the mental map for
banking became different between users and non-users of ATMs.1 Over a 30-year period,
the use of ATMs became commonplace in the developed world and, more slowly, is
making inroads in less-developed countries. Over time, the concept of banking is
aligning internationally, across languages and cultures.
Shared experiences & mental maps
Throughout a person’s lifetime, language “provides the most complex system of the
classification of experience,” and is “the most flexible and most powerful tool developed
by humans” (Duranti, 1997). This system of classification includes non-verbal ways of
knowing and being that take particular form in specific settings and involve subtleties of
meaning. This is of particular importance in health and mental health care experiences
that can be emotionally laden. To communicate most effectively with others, people
need to understand how others view and talk about health, illness, physical and mental or
emotional status. This system of classification is a mental map that links words to their
context and meaning.
Similar points of reference (or associations) can arise from common experiences.
Because of shared experiences, mental maps can take on similarities that allow shortcuts
1
The concept of the modern ATM first began in 1968; a working prototype came about in 1969.
Docutel was issued a patent in 1973, and the first working ATM was installed in a New Yorkbased Chemical Bank. Don Wetzel, Vice President of Product Planning at Docutel; Tom Barnes,
the chief mechanical engineer; and George Chastain, the electrical engineer, are listed on the
patent. It took $5 million to develop the ATM.
http://inventors.about.com/library/inventors/blatm.htm
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in how people speak. Frequent contact may enable people to build on past conversations
and develop a shared vocabulary; through work or play, people communicate with others
with whom they have shared experiences. For example, work environments often have a
culture of their own. People become accustomed to communicating as if word meanings,
systems of classifying experience, or mental maps are the same—so much so, that when
gaps occur in communication, they often go unnoticed.
Over time, people living together in proximity, sharing a history, a common worldview,
and a common language, are said to form a distinct identity or culture that distinguishes
them from other groups. Just as all English or Spanish speakers, for example, do not
speak their language in exactly the same way, all persons within a cultural group do not
live their lives in exactly the same way. There are myriad differences in both language
and culture (e.g., regional, occupational, and class—just to name a few). Although people
with common experiences are likely to form similar mental maps, none are identical. For
example, there may be variations in the meaning of 9/11 to people in New York City
when compared with those in Chicago.
Diversity as a product of sociocultural processes
In Speaking of Health: Assessing Health Communication Strategies for Diverse
Populations (2002), an IOM subcommittee examined how culture and ethnicity are
defined and operationalized. The report asserts that cultural processes and life
experiences are durable influences in shaping both individuals and groups. Moreover, the
IOM views diversity as a product of sociocultural processes. Historically, in the United
States, diversity has been narrowly viewed as only race and ethnicity. Regrettably, in
many instances, race and ethnicity continue to be the primary basis by which groups of
people are perceived, classified, and defined. Contrary to this view, there are numerous
cultural factors that influence diversity among individuals and groups. Such factors
include, but are not limited to: geographic location; population density; population
stability (e.g., rates of in-migration, out-migration, interstate migration, and immigration),
see Campbell (1997); age distribution of the population; social history; inter-group
relationships; and social, political, and economic climates. Still other factors influence
diversity among individuals and groups, such as language, nationality, acculturation,
assimilation, age, gender, sexual orientation/identity, education, literacy, socioeconomic
status, political affiliation, religious/spiritual beliefs, and health and mental health beliefs
and practices. A thorough understanding of these factors and their dynamics is essential
for effective communication among this nation’s diverse populations (Goode, 2001).
II. Communication, Culture, Health, and Mental Health Care
In a diverse society in which many cultures and languages are represented, common
knowledge and mental maps about illness, disease, treatment, and wellness may not be
shared by patients and providers. This cultural diversity makes information exchange
more difficult and miscommunication or misunderstanding more likely. Disease
prevention, diagnosis, and treatment depend heavily on clear communication between
patients and providers (DiMatteo, 1995; Frymoyer & Frymoyer, 2002; Levinson, 1999;
Neuwirth, 1999; Schneider, Kaplan, Greenfield, Li, & Wilson, 2004).
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Language diversity in the United States
The number of languages and cultures represented in U.S. patient populations, especially
in large urban areas, presents problems of scale: no health care facility has staff who
speak all the languages and dialects occurring among its patients. The U.S. Census
Bureau reports that over 300 languages were spoken in the United States (U.S. Census
Bureau, 2004). Census estimates that 47 million people (or 17%) speak a language other
than English at home. Although the majority speak English proficiently, a significant
number do not. In fact, there are over 11 million children and adults (almost 5%) who are
linguistically isolated. The Census Bureau defines linguistic isolation as living in a
household in which no person over the age of 14 years speaks English at least very well
(Census Bureau, see http://factfinder.census.gov/servlet/SAFFPeople?_sse=on). Finally,
immigration to and migration within the United States are occurring at a high rate,
ensuring that significant language and cultural differences will continue to impact health
care services for the foreseeable future.
Perspectives on literacy & health literacy
An estimated 90 million adults have lower-than-average reading skills—the latest
national data from the National Adult Literacy Survey, 1993, which found that
40 million adults scored at the lowest level of literacy measured, and another 50 million
scored at the second lowest level. Both of these levels correspond to difficulties in
synthesizing information from complex texts; some individuals scoring at the lowest
level were unable to respond to most of the survey. This study also found that “Black,
American Indian/Alaskan Native, Hispanic, and Asian/Pacific Islander adults were more
likely than White adults to perform in the lowest two literacy levels” (Kirsch, Jungeblut,
Jenkins, & Kolstad, 1993). It should also be noted that a segment of the population may
be neither literate in English nor in their language of origin. Studies show the that persons
with low literacy skills are less likely to (1) seek and get preventive care, (2) understand
forms for informed consent, (3) understand their children’s diagnosis, (3) understand
medication instructions for themselves and their children, and (4) be knowledgeable
about the health effects of risks, behaviors, and diseases (AHRQ, 2004).
An emerging body of literature sheds light on the role of health literacy. Although an
individual may indeed have excellent literacy skills, that individual may not be literate in
the complex terminology used in medical, health care, and mental health care settings.
Healthy People 2010 defines health literacy as “The degree to which individuals have the
capacity to obtain, process, and understand basic health information and services needed
to make appropriate health decisions.” (DHHS, retrieved 2005). The IOM states that
“even people with strong literacy skills may have trouble obtaining, understanding, and
using complex health information: a surgeon may have trouble helping a family member
with Medicare forms; a science teacher may not understand information sent by a doctor
about a brain function test; and an accountant may not know when to get a
mammogram.” (Report Brief on Health Literacy: A Prescription to End Confusion, 2004;
retrieved February 2, 2005, from http://www.iom.edu/Object.File/Master/19/726/0.pdf)
The IOM clearly states that health literacy does not rest with the individual. A recent
article in the American Journal of Preventive Medicine (Gazmararian, Curran,
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Parker, Bernhardt, & Debuono, 2005) emphasizes the importance of the providers’
communication skills in building health literacy among the public. The National Center
for Cultural Competence (NCCC) includes health literacy in its definition of linguistic
competence. In this definition, emphasis is placed on the capacity of an organization and
its personnel to convey information in a manner that is easily understood by diverse
audiences. Moreover, an organization must have policy, structures, practices, procedures,
and dedicated resources to support this capacity. See the Resources section.
There are different ways of conceptualizing health literacy.
Nutbeam (2000) described health literacy as comprising three levels: Level 1 is
functional health literacy, which is based on factual knowledge of health risks or ways to
use the health system; Level 2 is an interactive health literacy, which involves the use of
personal skills such as a capacity to make decisions based on health knowledge,
motivation, and self-confidence in acting on health knowledge; and Level 3 is critical
health literacy, which is individual and community capacity to influence the social and
political environment to improve the underlying social and economic determinants of
health.
The Health Literacy Component (HLC) of the 2003 National Assessment of Adult
Literacy (NAAL) offers a three-component model of health literacy that defines areas of
health literacy as clinical, prevention and navigation of healthcare systems (U.S. DHHS,
2003).
 The clinical type addresses interactions between the patient and the healthcare
provider, diagnosis and treatment of illness, and medication, requiring skill and
ability to: 1) complete a patient information form for an office visit, 2) understand
instructions for taking/administering medication; 3) understand activities needed
for self-management of acute or chronic illness; 4) follow provider
recommendations for diagnostic testing; and 5) provide accurate information for a
medical history, in verbal or written format.

The prevention type is associated with maintenance and improvement of health,
prevention of disease and early intervention in emerging health conditions, and
engaging in healthy behaviors and self-care. Such activities necessitate the ability
to: 1) identify signs and symptoms of a health problem that requires intervention
by a healthcare provider; 2) follow guidelines for preventive health services; and
make modifications to decrease risks of developing serious illness.

The navigation type is related to understanding how a healthcare system works,
including knowledge and awareness of individual patient rights and
responsibilities, familiarity with vocabulary, concepts and processes necessary to
use the healthcare system. The ability to navigate a healthcare system requires:
1) knowledge of health insurance plan benefits (covered and uncovered services);
2) capacity to determine eligibility for public health insurance assistance; and
3) ability to provide informed consent for a health care service.
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Another model of health literacy is adapted from models of literacy (see National Adult
Literacy Survey [NALS], International Adult Literacy Survey [IALS], and ETS Literacy,
at www.ets.org). This model defines categories of literacy skills as follows: prose literacy
(how well someone understands and uses information, e.g., in newspapers, manuals,
flyers, and brochures); document literacy (how well someone uses information in forms,
schedules, charts, graphs, and tables); and quantitative literacy (how well someone uses
numbers found in forms, flyers, articles, and other printed material, including the ability
to perform mathematical calculations). According to this model, health literacy is how
well one follows instructions, for example, on how to take medication, use information
on product labels, read an article about nutrition, fill out a patient history form, and read a
summary of medical test results, clearly building on prose, document, and quantitative
literacy skills.
Rima Rudd, of the Harvard School of Public Health’s National Center for the Study of
Adult Learning and Literacy, developed a Powerpoint presentation that specifically
describes different skills in health literacy. A copy of this presentation is available at
www.metro.org/SIGs/pdfs/chi_rudd_4_30_02.ppt). Wendy Jones, of the National Center
for Cultural Competence, refers to Dr. Rudd’s work in training on linguistic competence.
Ms. Jones added content describing the bullet points of Dr. Rudd’s work in further detail.
This excerpt is available for download here. (JR, please link to Wendy’s powerpoint,
attached).
Communication with people who experience disabilities.
There is a broad range of individuals who have differing communication needs that merit
attention within this nation’s health care and mental health care delivery systems. The
capacity to communicate may be impacted by many factors, including but not limited to:
speech or language disorders, hearing loss, low vision and blindness, traumatic brain
injury, stroke, dementia, intellectual disabilities, developmental disabilities, and serious
mental illness.
Many health and mental health care systems and organizations have not provided
extensive training to personnel on appropriate ways to communicate with and about
people with disabilities. One of the most common problems is referring to people by their
disability rather than their personhood (e.g., “the mentally retarded,” “the quadriplegic,”
“the schizophrenic,” “the wheelchair bound,” and “the borderline”). People first
terminology is the standard that should govern all communication about this population.
Training and policy within health and mental health care organizations should require
people first terminology such as individuals with developmental disabilities, a person
with intellectual disabilities, and a patient with a physical disability or communication
disorder.
Many personnel are not fully aware of the organizational policy and legal mandates to
ensure full accessibility for people with disabilities in this nation’s health and mental
health care systems. It is incumbent upon organizations to (1) establish policy that is
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consistent with federal and state mandates, (2) develop appropriate procedures and
practices, (3) provide training to all personnel and volunteers, and (4) monitor
compliance. For more information, see the Americans with Disabilities information and
technical assistance Web site at http://www.usdoj.gov/crt/ada/.
Some health care systems and plans have gone beyond legal requirements to promote
excellence in care. They build and maintain partnerships with people with disabilities,
conduct research, and disseminate findings and lessons learned in order to contribute to
the field and improve the overall quality of life for people with disabilities and their
families. Examples of such organizations include, but are not limited to:
many of the Leadership Education in Neurodevelopmental and Related
Disabilities, or LEND, programs; see the Association of University Centers on
Disabilities at http://www.aucd.org/aucd_lend.htm, in particular, the New Mexico
LEND program at http://cdd.unm.edu/NMLend/, which is a very strong program
that clearly articulates and emphasizes family-centered, culturally competent
values and principles throughout the training;
the Oregon Health & Science University’s Oregon Institute on Disability &
Development at http://www.ohsu.edu/oidd/;
the University Centers for Excellence in Developmental Disabilities, Education,
Research, and Service http://www.aucd.org/aucd_aboutuce.htm; and
the National Institute on Disability and Rehabilitation Research (NIDRR) at
http://www.ncddr.org.
Other health systems have initiated change in response to legal challenges, such as Kaiser
Permanente, which was sued in California by Disability Rights Advocates. As part of the
settlement, Kaiser Permanente established two facilities to serve as models of access to
individuals with disabilities, and appointed an access coordinator.
The Disability is Natural Web site offers articles, books, and other materials designed to
“encourage new ways of thinking about disability and to help create a society in which all
people are valued and included” (retrieved from www.disabilityisnatural.com). In fact,
new definitions of disability are emerging that reflect this thinking. For example, NIDRR,
National Center for Medical Rehabilitation Research’s definition is: “Disability arises at
the interface between a person’s functional abilities and the environment’s accessibility.”
The Web site also has information on disability etiquette and tips on communication with
individuals with disabilities. One of the best take-home tips is, “When you see, meet, or
think about a person with a disability, presume competence”
(www.disabilityisnatural.com).
The Roeher Institute in Canada offers a variety of resources on the connections between
literacy and disability. For example, although training programs to improve literacy
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among adults are very important, such programs alone are insufficient for a variety of
reasons, particularly for persons with intellectual disabilities (Roeher Institute, 1999).
They offer the following redefinition of literacy: “To be literate is to have the status,
respect, and accommodation from others; skills in communication (verbal, written, sign,
gestural or other language and access to the information and technologies, that make
possible self-determined participation in the communication processes of one’s
communities and broader society” (Roeher Institute, 1999, p. 17). This definition places
literacy skills in an environmental context and demonstrates the limitations but also the
adaptability of these “communication environments” that can be restructured to
“maximize the literacy skills that people have” (p. 29).
See the Resources section for more information on communication and disabilities.
III. Communication and Quality of Care
Communication, the sending and receiving of messages, is essential to all interactions. It
is the process by which one makes oneself known and gathers information to understand
others. Successful communication requires that the sender and receiver be aware of the
informational needs of the other to ensure that messages are conveyed effectively and
that the intended meaning is maintained (Owens, 2005). This process is impeded when
the sender and the receiver speak different languages.
Communication problems in health care settings are inefficient, costly, and pose serious
risks (Barrier, Li, & Jensen, 2003; Hausman, 2001; Kaplan et al., 1996; Levinson, 1999).
Such problems are inefficient, for example, because providers may rely solely on tests
instead of patients’ descriptions of their symptoms for diagnosis. Increased risks may
result when a patient does not comprehend enough of what the provider is saying to
understand and follow critical treatment recommendations, including medical adherence.
Communication difficulties prevent development of the rapport and trust between
patients and providers necessary for effective therapeutic alliances and patient-centered
care.
The quality of provider-patient communication is a critical factor for effectiveness in
health and mental health care. The accuracy and clarity of communication are associated
with patient and physician satisfaction, patient compliance, improved health outcomes,
better informed medical decisions, and reduced malpractice suits (Levinson, 1999;
Frymoyer & Frymoyer, 2002). A selected review of literature yields the following
evidence:
 In a study to understand the role of communication in medical malpractice claims,
primary care physicians who spent more time telling patients what they were doing
and what would happen next, who laughed and used humor, and who tended to
solicit patients’ opinions, checked understanding, and encouraged patients to talk
had fewer malpractice claims (Levinson, Roter, Mullooly, Dull, & Frankel, 1997).
 Patients’ ratings of the effectiveness of provider communication was strongly
associated with successful diabetes self-management (Heisler et al., 2002).
 Health outcomes are heavily influenced by the effectiveness of communication
between older patients and their providers. Shared expectations and including older
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







patients in the decision-making process contributes to effective communication,
improved patient recall, adherence, and satisfaction (Stewart, Meredith, Brown, &
Galadja, 2000).
A study that implemented better communication under a collaborative care model,
which included telephone contact to offer reminders and review treatment, resulted
in a moderate increase in days free of depression and in treatment cost (which the
authors related to increased interventions) (Liu et al., 2003).
A study of communication training at a state mental health hospital found that the
unit which received this training had less staff turnover, less sick and annual leave,
fewer patients’ complaints, and fewer assaults on staff, all resulting in substantial
cost savings for this unit compared to a control unit at the hospital (Smoot &
Gonzales, 1995).
Several studies observing interactions between physicians and patients from
1975 to 2000 show an association between communication and health outcomes.
Better health outcomes are associated with verbal behaviors that included empathy,
reassurance, and support; various patient-centered questioning techniques;
encounter length; history taking; explanations; both dominant and passive physician
styles; positive reinforcement; humor; psychosocial talk; time in health education
and information sharing; friendliness; courtesy; orienting the patient during
examination; and summarization and clarification. Non-verbal behaviors included
head nodding, forward lean, direct body orientation, uncrossed legs and arms, arm
symmetry, and less mutual gaze (Beck, Daughtridge, & Sloane, 2002).
Courtesy, formal greeting, and formal closure of an interview, information giving,
and listening behavior were found to positively affect patient satisfaction.
(Comstock, Hooper, Goodwin, & Goodwin, 1982).
Physicians with positive attitudes showed more empathy, offered reassurance, used
fewer closed-ended questions, and provided relatively more psychosocial and less
biomedical information. Patients respond to these physicians; they participate more
actively in their care by expressing opinions and by asking the physicians questions
(Levinson & Chaumeton, 1999).
Medical schools have begun to teach communication skills to physicians in training
and to offer continuing medical education programs to practicing physicians in
recognition of the importance of communication and the need for improved patientinterviewing skills (Brown, Bratton, Cabana, Kaciroti, & Clark, 2004; Dube,
O’Donnell, & Novack, 2000; Duffy et al., 2004; Gjerde, Kokotailo, Olson, & Hla,
2004; Kern et al., 2005; Rosen et al., 2004).
The increased awareness of the importance of good physician-patient
communication to good health outcomes has contributed to national certifying
examinations assessing communication skills. Although written materials and
testing are useful, behavioral change is more likely to occur in a workshop
environment (Frymoyer & Frymoyer, 2002).
Brach, Fraser, & Paez (2005) call for recognition of “language assistance as an
integral part of quality” (p. 430).
Many health care providers are reasonably perplexed about how to serve linguistically
and culturally diverse groups presenting to them for care. It is virtually impossible for
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anyone to have a deep or even a working knowledge of all cultural groups, given this
nation’s tremendous cultural diversity, nor is it expected. A basic tenet of cultural and
linguistic competence is having awareness, knowledge, and skill sets to work effectively
cross-culturally. Moreover, many tools and other resources have been developed for
health care and mental health care organizations and their personnel to build capacity.
IV. Process of Inquiry: Attitudes and Knowledge
This section discusses the Process of Inquiry as an approach to communication with
diverse populations in health and mental health care. It also presents other tools,
intervention strategies, and resources to assist providers in navigating the complexities of
caring for diverse populations.
It is important to maintain an inquiring perspective and pay attention to different patterns
of response related to how events or words are conceptualized by different groups of
people. Doing so helps with understanding that these differences may not be particular to
one person, but rather a pattern influenced by a way of life or belief system. It also helps
to suspend judgmental attitudes and unconscious bias that often arise in cross-cultural
communication. Because language is learned within a cultural context, experiences will
shape the associations a person makes between an event, idea, or concept and a word.
Communication with persons who come from different cultural and social contexts than
our own may require active attention and questioning using a Process of Inquiry.
Through this process, it is hoped that providers and patients can develop a deeper
understanding of how each uses language as a tool for communication and how each
represents concepts or ideas within their language. This process also extends to nonverbal communication. Effective communication in health and mental health encounters
requires verification to determine whether understanding has occurred.
Good communication between providers and patients needs to bridge wide differences in
lifeways as well as knowledge and language around health care. Figure 1 summarizes
these differences.
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Figure 1. Communicating Across Differing Cultural Mindsets2
(Figure 1. Copyright M. Jean Gilbert, 1998)
Figure 1 depicts a patient and a health care provider attempting to communicate about
symptoms. Each approaches the subject with very different facts and concepts. Each,
therefore, has a very different mental perspective about what is being discussed, whether
it’s a headache, nasal congestion, or anxiety. Communicating around symptoms will be
used as the basis of discussion on mindsets to illustrate the interacting factors of culturelanguage link and the Process of Inquiry.
Mindsets don’t just appear, rather Figure 1 suggests ways that they are acquired. The
provider can gain insight into a patient’s mindset by using the Process of Inquiry. Selfinquiry on the provider’s part will help clarify points of similarity and difference in
mindsets that will need to be communicated, discussed, and negotiated in order to
achieve collaboration and mutual trust in the patient-provider relationship.
A. Human physiology is universal. Although there are differences in size, shape, color,
and personality, human beings are put together in basically the same way. Many people
from all cultures are fairly uncertain about the location and functions of their anatomical
parts or how the operation of one part affects the others. [If you don’t believe this, try
asking someone who is not a health care provider where his or her pancreas is and what it
2
the term mindset is from Mindsets: The role of culture and perception in international relations
(1988), by Glen Fisher, Yarmouth, ME: Intercultural Press.
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does!] People from different cultures place varying degrees of importance on the
functions they believe to be those of specific organs or anatomical features; therefore,
they may be differentially concerned about symptoms they believe to be associated with
those specific body parts or emotional functioning. A headache by any other name is still
an ache in the head, but it may have very different meanings and significance across
cultures. For the provider, a headache may be important as one symptom in a possible
diagnosis; for patients, it may be the symptom that tells them they are experiencing soul
loss. Human beings experience their bodies differently, having been taught to do so by
their cultures. The way they speak about their bodies and emotions will reveal these
differences.
Process of Inquiry: Inquire gently about how patients see their physical, emotional, and
sexual selves. Inquire why they think the symptoms they are describing are signs of
illness or disorder. Inquire of yourself how your mindset regarding the described
symptoms was developed and why it might differ from that of your patients. Think
analytically about what the similarities and differences in your mindsets are, and how
you can use these understandings in your communication with patients, capitalizing on
the similarities and showing respect for differences even while expressing your
perspective.
B. No matter how much human beings share, each individual is unique—
physiologically, psychologically, and socially. The individual’s unique physical and
psychological self contributes to his or her mindset. The experience of illness and pain or
health and well-being creates a frame of reference for the meaning of the symptoms that
are being described and discussed. Within this frame, culture and language have a
significant effect: Individuals may experience illness and pain, but have learned culturally
appropriate ways to enact the “sick role” and the expression of pain. These culturally
defined beliefs and behaviors will affect the way the individual describes symptoms. All
individuals are unique in their life experiences and the ways in which their cultures shape
their mindsets. Do not make assumptions about the extent to which individuals are a
reflection of their cultural backgrounds. Self-inquiry can help uncover stereotypes and
unconscious biases that often plague our mindsets. For example, implicit association tests
designed to measure hidden bias, developed by researchers at Harvard University, are
available at https://implicit.harvard.edu/implicit/demo/measureyourattitudes.html.
Process of Inquiry: Inquire about your patients’ living environment, sexual identity,
family, and barriers they have experienced in accessing care and following treatment
plans or recommendations. Inquire of yourself what your reactions are to these unique
persons and their life situation, and think about what aspects of your background may
have shaped those reactions. Use the results of these inquiries as a basis to communicate
(1) your comprehension and empathy and (2) the importance of these factors in the
approach to their care.
C. Presume difference in health beliefs. Concepts of etiology, or causes of illnesses or
disorders, and associated beliefs about appropriate treatment vary considerably across
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cultures. Your training and background will likely lead you to an etiological
understanding of the symptoms that individuals seeking care from you may or may not
share. Your recommendation for further diagnostic testing and/or plans of care will be
based on your professional expertise and established protocols. However, coming to
consensus regarding diagnostic procedures and plans of care may require ongoing
dialogue and negotiation with individuals based on their theory of causation and
appropriate treatment.
Process of Inquiry: Inquire about the patient’s perception of the cause of his or her
symptoms. If the patient’s beliefs about the etiology and treatment and yours differ,
attempt to find areas of similarity or agreement. Inquire about potential areas of
compromise such as phasing in a treatment plan or different setting for treatment
(e.g., home instead of hospital). Inquire about and incorporate traditional treatment
modalities if they are of no potential harm. Ensure that your communication (verbal and
non-verbal) with the patient about such beliefs and traditional treatments does not
convey judgment and condescension. Inquire of yourself about which aspects of care you
can adjust or modify to meet the needs and preferences of the patient and which you
cannot. If the patient refuses your etiological explanation, does not adhere to the
recommended plan of care, or withdraws from care, assess your responses and what you
learned from the experience. Reflect on how you will handle similar experiences in the
future. Discuss these experiences with your peers to gain insight and obtain additional
support.
D. There is probably no more important aspect of culture than the norms for
behavior. This aspect of culture is particularly evident in interpersonal interactions and
role relationships. Norms form the context for day-to-day life in which any health or
mental health issue is embedded. These norms guide much of what individuals think and
do within their social surroundings. They define what the significant people in their lives
expect of them and also what they can expect from others. They define the following
framework of social support for individuals’ health behaviors: preventive measures,
symptom recognition, and treatment regimen. Norms also underlie the expectations that
individuals have of their health or mental health care provider.
Process of Inquiry: Inquire of your patients whether they have discussed their symptoms
and the probable cause of them with anyone or had anyone identify their illness, suggest
a treatment, or help them treat it. Inquire whether there are family, friends, or significant
others whom the patients would like to include in the inquiry and discussion. Ensure that
you do not exclude anyone from the patient’s support system because of your own beliefs
or mindset. For example, some within the patients’ networks of support have been
excluded by providers citing confidentiality and privacy statutes and procedures. Inquire
of your patients whom they can turn to for help if the symptoms worsen. Inquire about
how much material, financial, and emotional support is available to your patients,
particularly when patients have chronic disease or multiple diagnoses. Inquire about
your patients’ living environment/household. This may include, but is not limited to:
(1) setting; (2) household composition including any family members with disabilities,
special health care needs, or advanced age; (3) neighborhood or geographic locale; and
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(4) varying levels of English ability. Inquire about the patients’ living or interpersonal
dynamics that will facilitate or impede treatment. Inquire about what patients hope for in
the current encounter/visit and, where necessary, over the longer term. Inquire what
patients (and/or family members, significant others, or networks of support) expect in
terms of symptom alleviation. Inquire of yourself which of these expectations you can
meet, and how you will clarify with patients and their families and others those you
cannot.
The process of inquiry outlined above started with mindsets relating to symptom
identification, definition, and meaning. However, communication aimed at eliciting and
understanding symptoms moves far beyond this because symptomatology is an aspect of
a system of health beliefs. All health belief systems are embedded in a worldview. For
meaningful communication about presenting problems between patients and providers, it
is essential that the provider gain some understanding of how the patient “sees” the
problem. Only from this understanding, partial or in depth, can the provider have
effective communication with the patient, discussing and negotiating a mutually
acceptable understanding of the problem and arriving at an appropriate plan of care.
Clearly, such a process of inquiry is difficult to conduct in a single patient encounter,
visit, or other intervention. It is up to the provider to conduct the process of inquiry, the
depth or focus of which will depend on the patient’s linguistic and cultural
characteristics. If the patient and provider do not speak the same language or even speak
different variations of the same language, this should alert the provider to seek additional
supports such as the services of an interpreter or a cultural broker. The process of inquiry
is not a discrete occurrence. It is very beneficial applied over the course of care. The
process of inquiry is an essential skill set that should be integrated into a provider’s
approach to care.
V. Process of Inquiry: Skill Building and Tools
This section offers a selected set of models and tools to enhance the capacity of providers
to infuse the process of inquiry as an integral part of the delivery of care. More than
two decades ago, a group of physicians and medical anthropologists noted that their
increasingly diverse patient populations had varying concepts of health and illness. They
saw that patients from different cultures had different explanatory models for their
illnesses. Arthur Kleinman, Leon Eisenberg, and Byron Good (1978) wrote a seminal
article describing how providers could elicit the patients’ understanding of their own
health problem. They listed a set of questions that have been used and adapted, but not
improved on. These questions can be very useful in a process of inquiry. The following
chart is an excerpt from the original 1978 article (p. 256).
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Kleinman’s Explanatory Model of Illness
What do you think has caused your problem?
Why do you think it started when it did?
What do you think your sickness does to you? How does it work?
How severe is your sickness? Will it have a short or long course?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from this
treatment?
What are the chief problems your sickness has caused for you?
What do you fear most about your sickness?
The following mnemonic model is adapted by the NCCC from Berlin & Fowkes (1983).
The LEARN Model
L= Listen to what patients say with sympathy and understanding. Listen to the patient’s
perception of the problem without imposing values that may conflict or be inconsistent
with those of other cultures or ethnic groups.
E = Explain your perceptions of the problem and Empathize by understanding that the
perception of illness and disease and its causes varies by culture.
A= Acknowledge and discuss the differences and similarities and recognize that culture
influences help-seeking behaviors and attitudes toward health care and mental health care
providers.
R= Recommend treatments that respect individual preferences and are based on an
integrated approach to care.
N = Negotiate agreement and Navigate through complicated health and mental health care
delivery systems with and on behalf of patients.
Note: LEARN only works when you are able to communicate with the patient. Federal law
stipulates the critical importance of accommodating persons with limited English
proficiency in health and mental health care settings. You may need to learn to work with an
interpreter. Accurate communication is the foundation of proper diagnosis and treatment.
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A group of physician educators at the Robert Wood Johnson School of Medicine and
Dentistry of New Jersey associated with the Center for Healthy Families and Cultural
Diversity developed a set of questions similar to the Kleinman model (1978) based on the
mnemonic E.T.H.N.I.C. (Levin, Like, and Gottlieb, 2000).
ETHNIC
A Framework for Culturally Competent Clinical Practice
E= Explanation
What do you think may be the reason you have these symptoms?
What do friends, family, others say about these symptoms?
Do you know anyone else who has had or who has this kind of
problem?
Have you heard about/read/seen it on TV/radio/newspaper?
(If patients cannot offer explanation, ask what most concerns
them about their problems).
T= Treatment
What kinds of medicines, home remedies or other treatments have
you tried for this illness?
Is there anything you eat, drink, or do (or avoid) on a regular basis to
stay healthy? Tell me about it.
What kind of treatment are you seeking from me?
H= Healers
Have you sought any advice from alternative/folk healers, friends or
other people (non-doctors) for help with your problems? Tell me
about it?
N= Negotiate
Negotiate options that will be mutually acceptable to you and your
patient and that do not contradict, but rather incorporate your
patient's beliefs.
Ask what are the most important results your patient hopes to
achieve from this intervention.
I= Intervention
Determine an intervention with your patient. May include
incorporation of alternative treatments, spirituality, and healers as
well as other cultural practices (e.g. foods eaten or avoided in general,
and when sick).
C= Collaboration
Collaborate with the patient, family members, other health care team
members, healers and community resources.
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The following RESPECT model was cited as source unknown in Mutha, Allen, and
Welch (2002), a curriculum designed to teach health providers how to recognize cultural
differences in patient interactions and how to use specific communication skills to
improve patient care.
RESPECT model
Rapport
Connect on a social level.
See the patient’s point of view.
Consciously attempt to suspend judgement.
Recognize and avoid making assumptions.
Empathy
Remember that the patient has come to you for help.
Seek out and understand the patient’s rationale for his/her behaviors or illness.
Verbally acknowledge and legitimize the patient’s feelings.
Support
Ask about and try to understand barriers to care and compliance.
Help the patient overcome barriers.
Involve family members if appropriate.
Reassure the patient you are and will be available to help.
Partnership
Be flexible with regard to issues of control.
Negotiate roles when necessary.
Stress that you will be working together to address medical problems.
Explanations
Check often for understanding.
Use verbal clarification techniques.
Cultural Competence
Respect the patient and his/her culture and beliefs.
Understand that the patient’s view of you may be defined by ethnic or cultural
stereotypes.
Be aware of your own biases and preconceptions.
Know your limitations in addressing medical issues across cultures.
Understand your personal style and recognize when it may not be working with a
given patient.
Trust
Self-disclosure may be an issue for some patients who are not accustomed to
Western medical approaches.
Take the necessary time and consciously work to establish trust.
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Frankel and Stein (1999) developed a model for the clinical encounter entitled “The Four
Habits Model,” where each interviewing habit contains a skills set. The Four Habits are:
invest in the beginning, elicit the patient’s perspective, demonstrate empathy, and invest
in the end. Their article is available online from The Permanente Journal at
http://xnet.kp.org/permanentejournal/fall99pj/habits.html.
Additional tools are described in the curricula developed by Mutha, Allen, and Welch
(2002), “Toward Culturally Competent Care: A Toolbox for Teaching Communication
Strategies,” see http://futurehealth.ucsf.edu/cnetwork/resources/curricula/diversity.html.
Essential areas of inquiry
M. Jean Gilbert, a medical anthropologist, has identified areas of cultural life that have a
significant impact on health and well-being are often avoided or overlooked in health and
mental health care encounters. Across cultures, these areas hold potential for
misunderstandings and difficult communications, particularly because the specific
cultural norms and values that define these areas may differ quite dramatically from
culture to culture. Although these areas of culture may not be directly related to health
and illness per se, their impact on all aspects of patients’ lives is critically important.
They are fraught with emotional and cultural meanings that are often difficult to identify,
discuss, and probe. These areas can be quite sensitive for both providers and patients.
Patients may feel uncomfortable or vulnerable, and may be reticent to reveal what they
consider highly personal, private, sacred, or taboo. Additionally, these areas are likely to
be the unspoken sources of tension and may lead to problems in diagnosis and treatment.
Given these dynamics, it is incumbent upon the provider to include these areas in the
process of inquiry and to do so in a thoughtful, considerate, and respectful manner.
Failure to understand and address these areas can impede the provider’s ability to
communicate effectively and to provide quality care for the patient.
ESSENTIAL AREAS OF INQUIRY
Family involvement and perspectives
Family decision-making processes are culturally laden. Who is involved in decision making?
How do family dynamics affect the patient’s actions and reactions? Who, if anyone, must be
involved in communication other than the patient?
Personal autonomy and self-efficacy
Many cultures place different values on independence vs. interdependence in community and
family dynamics. How autonomous is the patient in determining his or her course of action? Does
the patient communicate confidence in his or her ability to perform the actions necessary for
participation in his or her own treatment? Are there family dependencies that might restrict this
participation?
Male-female roles
Male-females roles vary significantly among cultural groups. Cultures place rights and
responsibilities and sometimes restrictions on gender roles: husband/wife, son/daughter,
father/mother. Do these affect the patient’s reaction to diagnosis and treatment? Do role-related
restrictions affect communication with health and mental health care professionals?
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Sexual behaviors
Established norms for sexual behavior for men and women vary considerably among individuals
and across cultures (e.g., factors such as gender, age, marital status, generation, and
religious/spiritual affiliation). Are there any factors (e.g., religious beliefs or norms of modesty)
that may inhibit the patient’s responses to questions about sexual behavior?
Gender/Sexual identity
Gender/sexual identities are experienced uniquely and personally and are culturally influenced.
As a provider, can you identify when your perceptions of gender present obstacles in
communicating with your patients? In what ways can you communicate trustworthiness and
openness that will encourage patients to share their identity?
Pain expression and management
Pain is expressed differently and has different meanings among individuals and across cultural
groups. Do you check your assumptions for stereotypes about the pain tolerance? How can you
ensure that the communication between you, your patients, and their families results in effective
pain management?
End-of-life decision making
Strong cultural norms surround death and dying—for the patient, his or her family, and the
provider. Often, institutional policy and procedures around death and dying either do not take
cultural beliefs and practices into consideration or are in conflict with them. What do you know
about the beliefs and preferences of your patient and his or her family related to factors such as
disclosure of terminal status, end-of-life setting, who is involved in decision making, and cultural
or sacred rites? Do you incorporate these factors into your communication and approach to care?
Do you advocate with and/or on behalf of your patients, and their families, to ensure that their
decisions are honored and respected; and if they can’t be due to institutional policy or legal
requirements, how do you communicate this to the patients and their families?
Dietary beliefs and customs
Food and dietary beliefs, customs, and practices play a dominant role in the maintenance of
health and well-being, as well as in the prevention and treatment of disease. Such beliefs,
customs, and practices are culturally defined. Do you engage your patients in conversation
regarding their dietary beliefs and practices? Do you probe further to ascertain whether their
dietary practices are impacted by factors such as financial resources, accessibility of grocery
stores, and access to food storage and cooking facilities in their home environments? Do you
inquire of your patients whether they use specific foods, minerals, herbs, and supplements to treat
and/or manage disease or conditions? Do you ask questions that would elicit information to rule
out eating disorders?
A word about bias, stereotyping, and derogatory communication
Health and mental health care organizations and their personnel are not immune to bias,
prejudices, discrimination, and the broad range of “ISMs” (e.g., sexism, ageism, racism,
and others) in U.S. society. It is inevitable that providers will encounter bias in
themselves, their patients and their families, colleagues, supervisors and administrators,
and in the communities in which they serve. Providers need to master two critical skills:
(1) monitor your verbal and non-verbal communication for expressions of bias and
stereotyping and (2) intervene in an appropriate manner when biases are expressed by
others and make clear statements that such bias and/or stereotyping is unacceptable.
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The self-assessment checklist developed by Goode (1989, last revised 2004) “Promoting
Cultural and Linguistic Competency Self-Assessment Checklist for Personnel Providing
Primary Health Care” includes questions that help providers reflect on their own values
and attitudes. This checklist is available at
http://gucchd.georgetown.edu/nccc/documents/Checklist%20PHC.pdf.
Another resource is the “Toward Culturally Competent Care: A Toolbox for Teaching
Communication Strategies” (Mutha, Allen, & Welch, 2002), which contains exercises for
providers to examine personal values and beliefs (Section 1: Culture: Looking Within).
Communication styles
Communication styles vary across cultural groups. One of the most important distinctions
is between the more direct, explicit, context-independent style of some cultures and the
indirect, general, and context-dependent style of other cultures. In the former, words are
the primary means of communication; in the latter, non-verbal cues, understatement, and
the context supply much of the information. Differences in these communication styles
are particularly problematic during patient encounters which tend to be time-limited in
this nation’s health and mental health care systems: providers may be perceived as
brusque, rude, and unfeeling, and patients may be perceived as reticent, vague, and
avoidant.
Experts say that open-ended questions shift the encounter’s focus from simply an
information-gathering process for diagnosis of disease to a more broadly focused
interaction with patients around their experiences of illness (Kleinman, Eisenberg, &
Good, 1978; Rhodes et al., 2004; Berry, Wilkie, Thomas, & Fortner, 2003). The disease
paradigm is the main focus of biomedical culture; the illness model incorporates the
patients’ experiences of their symptoms and illness as they unfold in their lives. Asking
the patient to articulate his or her experiences around the illness enables providers to
identify misconceptions and differences in perception. It also allows providers to frame
communication with the patient in ways that fit the patient’s knowledge base.
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Goode (1989, latest update 2004) designed a checklist to heighten the awareness of
personnel in health, mental health, and human services settings to the importance of
cultural and linguistic competence. The following excerpt concerns communication styles
for personnel providing primary health care services, renumbered for this module.
COMMUNICATION STYLES
Directions: Please select A, B, or C for each item listed below.
A = Things I do frequently
B = Things I do occasionally
C = Things I do rarely or never
_____
1. When interacting with individuals and families who have limited English
proficiency, I always keep in mind that:
_____
* limitations in English proficiency is in no way a reflection of their level of
intellectual functioning.
* their limited ability to speak the language of the dominant culture has no
bearing on their ability to communicate effectively in their language of
origin.
* they may neither be literate in their language of origin nor in English.
_____
_____
_____
2. I use bilingual/bicultural or multilingual/multicultural staff, and/or personnel
and volunteers who are skilled or certified in the provision of medical
interpretation services during treatment, interventions, meetings, or other events
for individuals and families who need or prefer this level of assistance.
_____
3. For individuals and families who speak languages or dialects other than
English, I attempt to learn and use key words so that I am better able to
communicate with them during assessment, treatment, or other interventions.
_____
4. I attempt to determine any familial colloquialisms used by individuals or
families that may impact on assessment, treatment, health promotion and
education, or other interventions.
______ 5. For those who request or need this service, I ensure that all notices and
communiqués to individuals and families are written in their language of origin.
______ 6. I understand that it may be necessary to use alternatives to written
communications for some individuals and families, as word of mouth may be a
preferred method of receiving information.
_____
7. I understand the principles and practices of linguistic competency and:
_____
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* apply them within my program or agency.
_____
* advocate for them within my program or agency.
_____
8. I understand the implications of health literacy within the context of my roles
and responsibilities.
_____
9. I use alternative formats and varied approaches to communicate and share
information with individuals and/or their family members who experience
disability.
How to use this checklist
This checklist is intended to heighten the awareness and sensitivity of personnel to the importance
of cultural and linguistic cultural competence in health, mental health, and human service
settings. It provides concrete examples of the kinds of beliefs, attitudes, values, and practices that
foster cultural and linguistic competence at the individual or practitioner level. There is no answer
key with correct responses. However, if you frequently responded “C,” you may not necessarily
demonstrate beliefs, attitudes, values, and practices that promote cultural and linguistic
competence within health and mental health care delivery programs.
For the entire checklist, see
http://gucchd.georgetown.edu/nccc/documents/Checklist%20PHC.pdf.
See Section D for a self-discovery exercise in communication style.
VI. Applying the Process of Inquiry to Communities
Although the previous sections have focused on the process of inquiry at an individual
level, specifically patient and provider, can these concepts and strategies be applied to
learning about communities? Recent research shows some promise of applying the
concepts inherent in the process of inquiry at the community level (Bade, Murphy, &
Sullivan, 1999; Bowen, Gwiasda, & Brown, 2004; Chene et al., 2005, Faust et al., 2005;
Hausman et al., 2005; McArthur, Anguiano, & Gross, 2004; McKay & Bannon, 2004;
Rosen, Hiller, Webster, Staton, & Leukefeld, 2004; and Ruether, St Claire, & Coffman,
2002).
Evidence shows the clinical relevance of social, environmental, and cultural factors in the
entire spectrum from illness and disease to health and well-being (Bell & Standish,
2005). For example, in the Executive Summary of the 2001 IOM report entitled “Health
and Behavior: The Interplay of Biological, Behavioral, and Societal Influences”, the
authors state that “because the gradient in morbidity and mortality persists even between
middle class and well-to-do men and women, and even in societies in which material
conditions are very good, it seems unlikely that gradients are due solely to material
circumstances per se. It has become evident that community socioeconomic status
independently influences mortality” (p. 18). In addition, the report cites key lessons
learned, including:
 “the importance of the community, rather than an outside organizer, in defining
needs and priorities; the need for an initial and continuing community diagnosis
and assessment to identify and build on community strengths and resources;
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
the flexible implementation of theories and methodologies, tailoring them to a
particular community context;

the importance of using participatory and empowering approaches to evaluate
community-level change interventions” (pp. 13–14).
Providers should not treat patients in isolation from their social-cultural contexts. To be
effective, providers need to know about these contexts particular to the communities in
which their patients live and work. Health and mental health care organizations must
have policy, structures, procedures, and dedicated resources to promote the relevance and
ensure the systemic application of the process of inquiry.
The following are strategies for health and mental health care organizations and their
staff to conduct a process of inquiry and gain knowledge about communities:
 Key community informants. Many community members are willing to share
information about the life of the community. This is particularly true when they are
convinced that sharing this information will lead to benefits for the community. This
information sharing could take many forms including, but not limited to, structured
interviews, informal and formal sessions that allow for staff to query the informant,
and one-on-one consultation to provider, health educators, administrators, or policy
makers.
cultural brokering: This term has
 Cultural brokers. Cultural brokers can play multiple
multiple definitions. Cultural
roles including serving as key community
brokering is defined as the act of
informants or facilitating connections to other
bridging, linking, or mediating
between groups or persons of
informants or community networks. Additionally,
differing cultural backgrounds for the
cultural brokers can leverage their credibility within
purpose of reducing conflict or
communities to encourage and increase participation
producing change (Jezewski, 1990). A
by diverse community members in all aspects of the
cultural broker acts as a go-between,
process of inquiry. Lastly, the cultural brokers can
one who advocates on behalf of
another individual or group (Jezewski
act as catalysts for change by advocating for the
& Sotnik, 2001). A health care
institutionalization of policies and practices that
intervention through which the
enable organizations to gain knowledge about the
professional increasingly uses
communities they serve.
cultural and health science
 Focus groups. Health care organizations can use
knowledge and skills to negotiate with
the client and the health care system
this well-known method to inquire about areas such
for an effective, beneficial health care
as community perceptions of health, illness, barriers
plan (Wenger, 1995) For more
to care, and health and mental health disparities; and
information, see the Cultural Broker
other factors such as community and domestic
Guide
violence, rates of employment, work conditions
http://gucchd.georgetown.edu/nccc/do
cuments/Cultural_Broker_Guide_Eng
(e.g., multiple jobs, irregular hours, and physically
lish.pdf
demanding or hazardous work), housing conditions,
transportation, and economic viability (retail,
grocery, or employment opportunities), and changing demographics. Focus groups
should employ culturally and linguistically competent approaches and should ensure
they have diverse participation. For example, discussion suppers have been used in
rural areas to inquire and inform policy making (Faust et al., 2005)
Page 25 of 73


Advisory boards, task forces, and committees. Include community members on
advisory boards and other work groups to elicit their perspectives and expertise in
program planning, design, and implementation.
Participatory action research. The process of inquiry can be particularly powerful
when applied to research. According to Selener (1991), participatory action research
allows researchers to learn about the strengths, needs, and circumstances impacting
those they seek to assist, and offers opportunities for the community to learn about
the uses, requirements, limitation, and benefits of research. Participatory action
research demonstrates a major principle of community engagement that it must result
in the reciprocal transfer of knowledge and skills between all collaborators, partners,
and key stakeholders.
VII. Communicating With Limited English Speakers in Health and Mental Health
Care Settings
Effective communication in a multicultural environment requires linguistic competency.
There are numerous definitions of linguistic competence, as noted in Section B4 of this
module. Goode and Jones (2003, revised 2004) developed a broad definition of linguistic
competence, summarized as follows:
The capacity of an organization and its personnel to communicate
effectively, and convey information in a manner that is easily understood
by diverse audiences including persons of limited English proficiency,
those who have low literacy skills or are not literate, and individuals with
disabilities. Linguistic competency requires organizational and provider
capacity to respond effectively to the health literacy needs of populations
served. The organization must have policy, structures, practices,
procedures, and dedicated resources to support this capacity.
The most sensitive, inquiry-based approach to patients from culturally and linguistically
diverse groups is useless if providers and patients cannot communicate effectively.
The rapid growth of the population of patients with limited English proficiency has
challenged the health and mental health care systems. Although the federal government
and many states have statutory requirements to assure language access, health and mental
health care systems lag far behind in (1) recruiting and retaining a multilingual
workforce, (2) building the infrastructure, (3) developing and executing policy and
procedures, and (4) allocating the necessary resources for linguistic competency.
Numerous studies have documented the negative impact of language barriers on health
and mental health care outcomes (Carrasquillo, Orav, Brennan, & Burstin,1999; Karter,
Ferrara, Darbinian, Ackerson, & Selby, 2000; Muzyk, Muzyk, & Barnett, 2004;
Newcomb & Carmona, 2004; Ngo-Metzger et al., 2003; Westberg & Sorensen, 2005).
The data from these studies indicate that individuals with limited English proficiency, for
whom no language services are offered, are less satisfied with services, have worse health
outcomes, are less likely to return for needed services, and are less likely to understand
medications. Further, the potential for medical errors with such patients is increased.
There is a growing realization that linguistic competency is integral to quality of care and
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that an increasing number of initiatives are focusing on best and evidence-based practices
in this area. See the Resources section.
Translation Services
The terms interpretation and translation are often used interchangeably. The NCCC
makes a distinction between the two terms and provides the following definition (Goode,
Sockalingam, Brown, & Jones, 2000, revised 2003):
Translation typically refers to the written conversion of written materials from
one language to another.
Interpretation is the oral restating in one language of what has been said in
another language.
Examples of things that should be translated in health and mental health care systems
include, but are not limited to:
 signage, consent forms and other legal documents, medication and/or treatment
instructions, and pharmacy labels;
 evidence of coverage, patient rights and responsibilities, and other consumer
documents;
 health promotion or education materials, advocacy information, consumer alerts, and
public emergency instructions;
 policy briefs, reports, monographs, books, published and unpublished research
findings, federal, state, tribal, local, and organizational policy and procedures; and
 written aspects of media including DVDs, videos, and especially Web sites.
The Emerging Evidence on Translation Services
As evidence continues to emerge on best practices in the provision of translation services,
the work of Yolanda Partida, National Program Director, Hablamos Juntos, contributes
great insight to the field. The following are selected excerpts from Spanish Materials
Development: Hablamos Juntos Lessons Learned and Recommendations” by Dr.
Partida. See www.hablamosjuntos.org for the full text of this document.
“LESSONS LEARNED AND RECOMMENDATIONS
1. Development of Spanish materials is an after-thought in most health
organizations. Few organizations collect language preference data, and systems
to identify the information needs of limited English speakers are rarely found.
Policies or procedures to guide decision-making or the development of Spanish
materials are also rare. Legal and administrative documents (e.g. consent forms,
admissions forms, financial forms) represent the most common Spanish materials
available in organizations. Educational materials and patient instructions are also
commonly developed in Spanish. However, when translated materials are
available, they are usually the result of compliance efforts or the work of
champions within the organization, often a physician or health professional in a
decision making role.
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Recommendation
Health organizations should establish policies that engage staff in proactive
identification of the communication needs of all patients and specifically those who
face language barriers. This includes, at a minimum, collecting language preference
data and using performance improvement methods to identify communication needs
and challenges. The processes for developing written materials for LEP/NEP
populations should be developed, and decision-making steps and responsibility
should be defined. These steps should a) require a critical review of English
materials before a translation is attempted to determine how effective they are and
whether these actually accomplish the communication objectives intended; b)
centralize decision making and develop internal capacity to analyze the implication of
translating an English original and determine whether material should be translated or
not; c) prepare translation briefs and provide detailed guidance to translators about
how challenges encountered should be addressed; and d) insist on quality review of
materials with a focus on the usefulness of the translated text and the potential for
LEP patients to comprehend the intended meaning.
2. Responsibility and authority for Spanish materials is diffused within health
organizations, and it is often unclear who the decision makers are. Review and
quality standards applied to the production of English materials and forms such as
style guides, branding considerations, editing and various review and approval
processes (by committees or designated individuals) are typically not developed
or applied to the production of Spanish materials. This lack of structure
contributes to the production of materials that vary greatly in terms of quality and
appearance within organizations. Many organizations are unaware of what
materials they have, who translated the documents, and how the materials were
reviewed for quality. The appearance and branding of Spanish material is often
radically different from the English original.
Recommendation
Health organizations should designate a patient-communications officer whose
primary responsibility is to monitor the organizations success in communicating with
all patients and to address communication weaknesses. Quality review processes
need to integrate monitoring of the effectiveness of patient communication; results
can then be used to ensure the development of materials is based on the experience of
patients. The designated officer should work to increase awareness and
understanding of the role written materials can play in patient communication,
identify opportunities to improve what is known about different patient populations,
and prioritize implementation of solutions with a special emphasis on linguistically
diverse patient populations. Because of the broad reach of the role, the patientcommunications officer responsibility should rest with the executive team of health
care organizations.
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3. Translation of English materials is often done without considering the fit for the
new target audience. Text or materials developed by health care providers is
generally produced for a particular reader or readers, with a particular purpose,
and in a particular place in time. A thoughtful analysis is needed to determine
whether a translated version will meet the needs of a new audience, and can be
accomplished with the “Translation Brief.” However, most health organizations
we worked with were unfamiliar with it. The availability of text in English (or
urgency created by compliance concerns) and the idea that similar information is
required for limited English speakers is what drives action in an organization. The
question of whether to translate or not is typically only considered in relation to
cost, not in relation to the best way of conveying the given information to a
specific population. Rarely is there a process, formal or informal, to analyze
whether a translation will achieve the desired communication goal. Translators
with whom we spoke reported filling the void left by a lack of a translation brief
by asking questions informally. Unfortunately, too often translators must work
without even basic information about the communication goals and intent of the
text. Although the value of the translation brief is often underestimated by some
translators, experienced translators require basic guidelines, formally or
informally.
Recommendation
Health organizations should ensure that when translation is used its highest priority is
to preserve the communicative intent of the original materials. By using a translation
brief, differences between how the original audience and the LEP/NEP audience may
interact with the materials differently can be identified and guidance for adaptations
of the original can be given to a translator. The translation brief can be used to
customize and change new text to meet the needs of the new audience. Logically, a
formal process to determine communicative intent is required. Questions considered
in conjunction with the development of the translation brief should include: What is
the knowledge base assumed in the text? Can these assumptions be made for the
target audiences? What lifestyle demands do they have to contend with? Are
recommendations compatible with, cognizant of, and sensitive to differences in
beliefs and values? Are the recommendations or actions suggested feasible for the
new audience? Are there systems in place for the health organization to meet
promises made in the text?
4. Spanish materials evaluated by Hablamos Juntos indicated a lack of consensus
around how to deal with terms specific to the American health care context.
Materials do not systematically acknowledge a wide range of Spanish literacy
among U.S. Spanish speakers, unlike countries where Spanish is the dominate
language, and over emphasize regional and local varieties. Also missing is a
recognition that LEP/NEP patients will, over time, need to learn to function in an
English-language-based health care environment. Improving the quality of
Spanish materials and using these at tools to advance understanding of the English
environment can aid in this development.
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Recommendation
Develop Spanish materials acknowledging that patients live and work in an Englishspeaking context. Over time because they tend to be younger than the U.S.
population, many limited English speaking patients will increase their ability to
function in an English environment. Here are some ways non-English materials may
help with this learning process: a) use glossaries with English-Spanish definitions, b)
use English titles, program and department names, these are likely to be found in their
English form more easily than in translated forms, c) using subtext to define what a
department or program does in a directory would be more helpful than translated
names; d) similarly, limited English speakers may be better served by using English
terms for health related vocabulary and concepts (Caretaker, HMO, Member
Services) when these are defined in Spanish (this will also avoid translators having to
invent or create new Spanish equivalents which would have to learn; e) when there is
high variability in acculturation and English mastery, developing bilingual materials
should also be considered to enable readers to go back and forth between the two
languages. Finally, to help English only staff to distinguish non-English text, titles of
documents should remain in English with their Spanish translation as subtext. These
practices recognize that the U.S, Spanish speaking patents are straddling two
language worlds and serve to advance improved communication.
5. Most health organizations know that word-for-word translation has a limited place
and can even be detrimental to accuracy if applied blindly. However, insistence
on developing English equivalents, designed to limit the changes a translator can
make independently and to compensate for the lack of language skills needed to
determine quality and accuracy of the products commissioned has resulted in
word-for-word translation as the default position. The misguided practice of
back-translation and failure to examine the quality and usefulness of English
originals lead to thousands of dollars spent on translated text that is not useful to
patients.
Recommendation
Health organizations can increase their competencies in effective patient-provider
communication by learning about the challenges of communicating with LEP patients
and examining how well they are doing with English speaking patients. By designating a
patient-communication officer, a focal point is developed for the organization and
establishes communication as an explicit organizational priority. Formalizing the
processes for developing non-English text creates new opportunities to proactively
identify communication needs for linguistically different patients and simultaneously
develop materials. Considering the implications of text for limited English populations
may help highlight ambiguities and communication challenges that currently go
unnoticed for English speaking patients. Including bilingual experts, with superior
proficiency in both languages and familiarity with both English and Spanish speaking
populations served by the facility, on materials development and quality review
committees may improve all written materials. Learning to evaluate quality of all
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materials will help develop skills and resources to also evaluate the quality of nonEnglish materials. Field-testing materials with members of the target population and
using bilingual focus groups can help identify common issues across groups as well as
differences. Furthermore, the writing and reading skills of persons used to quality review
new materials should be formally assessed, and a professional who is knowledgeable
about the content conveyed in the materials should be included in the review process.
Finally, a third party evaluator can provide feedback on the quality of translated text. A
count of major and minor errors should help non-Spanish speakers to understand the
overall quality of the translated text. The person who commissions the translation can
specify from the outset the number of minor errors that will be allowed, but no major
errors (discrepancies in meaning between the two documents) should be accepted.”
For full text of this article ,see http://www.hablamosjuntos.org
For more information on best practices in translation, see
http://www.nccccurricula.info/communication/bestpractices.html
Interpretation Services
Although the health and mental health care workforce is diversifying in the number of
workers who are multicultural and multilingual, this is not occurring rapidly enough to
respond to the need in the patient population. Health and mental health care organizations
are responding to this dilemma by using interpreters, both trained and untrained, and
contracting with other technology-based language support, such as interpretation by
telephone or video (Internet) based. The following is an analysis of current trends in the
provision of interpretation services.
Untrained interpreters. A vast majority of health care organizations and professionals are
using two types of untrained interpreters: family and friends of the patient and bilingual
staff. Although it is against federal regulations to ask patients to supply their own
interpreters, many organizations and professionals are unaware of or unclear about these
regulations. In many instances, organizations use untrained bilingual or multilingual staff
(may be referred to as heritage speakers—those who learned a language at home and/or
in the community and may not be trained in medical or other interpretation, see
http://hablamosjuntos.org/is/index.asp). These staff include receptionists, dietary
workers, janitors, and clerks who perform interpretation on an ad hoc basis. Typically,
organizations justify such practices by citing lack of skilled staff and resources and by
having an attitude that this is the best that can be provided under the circumstances.
Organizations also hire bilingual or multilingual medical or clinical assistants who are
expected to perform interpretation as one aspect of their duties; these are often called
dual-role interpreters. Many dual-role interpreters are hired into entry-level positions that
may or may not require a high school education. Their language abilities may be assessed
only superficially or not at all.
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There are numerous problems with using untrained interpreters. These problems have
been documented in the use of family and friends, ad hoc interpreters, and dual-role
interpreters. The potential for miscommunication, medical errors, and possible liability
problems is significant when such untrained persons are used (Baker, Parker, Williams,
Coates, & Pitkin, 1996; Flores et al., 2003; Rivadeneyra, Elderkin-Thompson, Silver, &
Waitzkin, 2000). Quality of care is distinctly impeded. Unless the provider is somewhat
versed in the patient’s language, it can be very difficult to determine where errors in
communication are occurring. For information on “Special Problems in the Use of
Family, Friends, and Minors as Interpreters in Health Care Settings” and “Pitfalls in the
Use of Untrained Interpreters,” see Section D.
Trained or Certified Interpreters. The use of professionally trained interpreters is
considered best practice and can improve the quality of care to patients with limited
English proficiency (Jacobs et al., 2001; Lears & Abbott, 2005; Rhodes, 2000; Oquendo,
1996). Although national certification for medical interpreters is still not available,
standards for quality medical interpretation have been developed in California by the
California Healthcare Interpreters Association (CHIA) www.chia.ws, and in
Massachusetts by the Massachusetts Medical Interpreters Association (MMIA)
www.mmia.org. Further, an assessment guide has been developed by the National
Council on Interpreting in Health Care (NCIHC) www.ncihc.org recommending that
interpreters be assessed in the following areas:
 Basic language skills in the two languages,
 Ethics and ethical decision making,
 Cultural issues,
 Health care terminology,
 Integrated interpreting skills, and
 Written translation of simple instructions.
The NCIHC, a national organization for health care interpreters, lists on its Web site
18 state associations for health care interpreters. Many of these state organizations offer
training sessions, instructional meetings, and yearly conferences. Health care
organizations interested in improving the language proficiency and interpreter skills of its
bilingual and multilingual interpreting workforce can encourage and financially support
their personnel to participate in these organizations where available.
As mentioned above, Hablamos Juntos is providing leadership in the development of
promising and evidence-based practices in the field of language access, including
interpretation. It offers many resources and strategies for health care organizations
seeking to design, maintain, or enhance their interpretation services at
http://www.hablamosjuntos.org/is/default.index.asp.
Community interpreter banks can be the most cost-effective way to provide a wide range
of languages to a community, by sharing costs among partners, participants, or
customers. An interpreter bank can take a variety of forms, including but not limited to:
an accessible database of interpreters for a community; a community-based organization
that provides the interpreters as needed; or a pool of interpreters shared by community
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hospitals, clinics, or other organizations with similar language access needs.
examples of such cooperative programs, see the following:
For

Description of the “Remote video medical interpreter bank project, San Joaquin
General Hospital”, see
http://ntiaotiant2.ntia.doc.gov/top/docs/nar/pdf/066004023n.pdf.

Georgia Mutual Assistance Association Consortium,
http://www.gmaac.org/interpret_program.htm

Louisville, Kentucky created an Office of International Affairs to serve as a
clearinghouse of information and services to immigrants, refugees, foreign
students, and all international visitors. This Office runs a community language
bank. See http://www.louky.org/fp/oica/bank.asp
Numerous training opportunities are available for interpreters through organizations and
colleges. One example is Cross Cultural Health Care, which offers medical interpretation
training and other key resources at http://www.xculture.org/training/index.html. To link
directly to the well-known training program “Bridging the Gap,” see
http://www.xculture.org/training/overview/interpreter/programs.html.
There are also widely used publications such as: Language Barriers in Health Care
Settings, Health Care Interpreter Training in the State of California, and How to Choose
a Language Agency, funded by The California Endowment (see www.calendow.org,
Publications section, Cultural Competency category); Providing Language Interpretation
Services in Health Care Settings: Examples from the Field, funded by The
Commonwealth Fund, see www.cmwf.org.
Working with interpreters
Provider barriers. Data show that even when interpreters are available, health care
professionals underused their services for a variety of reasons, including cost, time, and
lack of knowledge of how to work effectively with interpreters. Even in situations in
which providers recognize that failing to use available interpreters may result in
suboptimal care, they may attempt communication in a language in which they are not
proficient, or use family members including children, or prevail on their proficient
colleagues, or avoid communication entirely with patients who have limited English
proficiency (Burbano O’Leary, Federico, & Hampers, 2003; Hornberger, Itakura, and
Wilson, 1997). Studies have shown conflicting data with respect to whether encounters in
which interpreters are used are actually more time consuming, but data consistently show
that the use of interpreters improves care for this patient population.
Hablamos Juntos published a report in 2004 with findings from focus groups conducted
with physicians who treat persons with limited English proficiency. The executive
summary and full report can be downloaded from
http://www.hablamosjuntos.org/physicians/.
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In a study by Karliner, Perez-Stable, and Gildengorin (2004), health care providers were
asked about their most recent patient encounter that involved an interpreter. Fewer than
half of the respondents were “satisfied with their ability to empower the patient with
knowledge about their disease, treatment or medication” (Abstract); although most
reported satisfaction with the medical care they provided in that encounter, they reported
difficulties in eliciting exact symptoms (71%), explaining treatments (44%), and eliciting
treatment preferences (51%). Providers who had previous training in working with
interpreters were more likely to use interpreters and more likely to be satisfied with the
medical care they provided. This study strongly suggests that health care organizations
have not systematically addressed language access in policy, procedures, and practices.
A number of medical and nursing schools include instructions and practice in the use of
interpreters in their curricula. This has, however, been a recent development, and many
practicing health care professionals have not had the benefits of such training. One
training organization, the Cross-Cultural Health Care Program in Seattle,
www.xculture.org, offers such a program called “Communicating Effectively Through an
Interpreter.” Another resource developed by Mutha, Allen, and Welch, at the Center for
the Health Professions, University of California, San Francisco, includes a section on the
role of the medical interpreter and specific tools, strategies, and exercises for working
with interpreters. See
http://www.futurehealth.ucsf.edu/cnetwork/resources/curricula/diversity.html.
For guidelines on using interpreters, see the Resources section.
Telephonic or other technology-based interpreting. The use of telephones and other
media has emerged as a method of providing interpretation services. Interpretation can be
provided when the patient and provider are together in one room, or telephone calls
between patient and provider can be patched into the telephonic interpreter. Advice
nurses and call centers can also patch into these services. When a provider initiates a
request for an interpreter with the telephonic dispatcher, a medical interpreter speaking
the requested language is usually available within 1 minute.
Telephonic services do not take the place of face-to-face interpreting, but they are critical
linguistic aids when health care organizations do not have access to interpreters who
speak a rare or uncommonly needed language. They are also useful to specialty practices
that have a low volume of referrals.
Other technology-based interpreting includes video interpreting and voice over Internet
protocol. For information, see https://www.fedvrs.us/help/about.asp and
http://www.fcc.gov/voip/. The Registry of Interpreters for the Deaf developed standards
on interpreting for a range of contexts, including medical settings
(http://www.rid.org/118.pdf) and mental health settings (http://www.rid.org/126.pdf).
Federal laws and guidelines related to language access
The following is a selected list of the federal laws and guidelines related to language
access, including their related Web sites:
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






Title VI, section 601, of the Civil Rights Act of 1964, see
http://usinfo.state.gov/usa/infousa/laws/majorlaw/civilr19.htm;
Executive Order 13166 http://www.usdoj.gov/crt/cor/13166.htm;
The Americans with Disabilities Act (ADA), see
http://www.usdoj.gov/crt/ada/adahom1.htm;
Section 255 and 251(a)(2) of the Communications Act of 1934, as amended by
Telecommunications Act of 1996, see
http://www.fcc.gov/cgb/consumerfacts/section255.html;
The Individuals with Disabilities Education Act (IDEA)
http://www.ed.gov/policy/speced/guid/idea/idea2004.html;
DHHS Guidance www.hhs.gov/ocr/lep/guide.html;* and
The Culturally and Linguistically Appropriate Standards (CLAS)
(http://www.omhrc.gov/clas/finalcultural1a.htm).*
*The U.S. Department of Health and Human Services issued these guidelines for
organizations that are in any part funded by federal monies. For a summary of the major
requirements under these guidelines and a summary of the CLAS standards applying to
language access, see the Appendix.
A number of states have followed suit with legislation or contract language requiring that
linguistic services be provided to patients with limited English proficiency in statesupported health and mental health care programs. These federal and state regulations
have been compiled by the National Health Law Program and are updated regularly at
http://www.healthlaw.org/langaccess/index.shtml. Additional information is available
from NCCC’s Policy Brief 2, Linguistic Competence in Primary Health Care Delivery
Systems: Implications for Policy Makers (Goode, Sockalingam, Brown, & Jones, 2000,
revised 2003), at http://gucchd.georgetown/nccc/documents /Policy Brief 2 2003.pdf.
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SECTION D.
TEACHING TOOLS, STRATEGIES, AND RESOURCES
This section provides a listing of areas of awareness, knowledge, and skills that students
in health and mental health care training programs need to acquire related to the process
of inquiry —communicating in a multicultural environment. These areas are equally
applicable for continuing education, professional development, and inservice training.
This section also provides additional instructional tools and strategies such as exercises,
activities, and guidance for faculty, trainers, or facilitators.
Areas of Awareness, Knowledge, and Skills
The NCCC selected the following areas of awareness, knowledge, and skills to highlight
in this module. This list is not exhaustive. Faculty are encouraged to adapt and enhance
the following characteristics based on the needs, interests, and areas of focus within their
respective disciplines and training programs.
Awareness












that language and culture are inextricably linked;
that the relationship between language and culture is dynamic and changes over
time and across settings;
of your own communication style (both verbal and non-verbal);
that there are a variety of patient communication needs and preferences (e.g.
health literacy, English proficiency, speech or language disorders, and cognitive
and related disabilities);
that patient-provider communication can either impede or facilitate the
effectiveness of health and mental health care;
of the literature that links communication and quality of care;
of the importance of communicating with patients in their primary language;
of federal and state laws and state, local, and agency policies that address
language access in health and mental health care services;
of key considerations in the provision of high-quality interpretation and
translation services;
of the concept of the process of inquiry and its applicability in health and mental
health care settings;
that using the process of inquiry can have a positive impact on the patientprovider relation and ultimately health outcomes; and
of the reticence among some patients to discuss issues they perceive as sensitive,
private, or taboo.
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Knowledge of










models and frameworks for effective cross-cultural communication;
the literature, emerging evidence, and innovations in cross-cultural and patientprovider communication;
the questions to ask to acquire clinically relevant information such as cultural,
gender, and sexual identities; health and mental health beliefs and practices;
family circumstances; community and environmental settings; and so forth;
how to apply the process of inquiry to oneself to explore one’s own mental maps,
mindset, worldview, biases and stereotypes, and attitudes;
a repertoire of statements to confront bias, stereotyping, and discrimination in the
health and mental health care setting;
different approaches and strategies to apply the process of inquiry to
communities;
strategies to work effectively with interpreters;
application of the federal and state statutes that protect the rights of individuals
with disabilities and limited English proficiency;
the implications of health literacy within the context of my roles and
responsibilities; and
culturally defined familial colloquialisms and terms used to express physical or
emotional conditions, symptoms, illness, and disease.
Skills to











apply models and frameworks for effective cross-cultural communication;
discern when, what, and how to communicate with patients on sensitive areas of
inquiry;
resolve and/or mediate conflict rooted in bias, prejudice, or discrimination;
plan and implement a process of inquiry for the community using a variety of
strategies (key community informant, cultural brokers, focus groups, advisory
boards, task forces and committees, and participatory action research);
assess the level of health literacy by applying one of the health literacy models
and by adapting communications with patients accordingly;
communicate and negotiate treatment options with patients and their families;
work effectively with foreign and sign language interpreters;
partner with patients to evaluate the efficacy of translated documents and signage;
partner with patients to evaluate the quality and effectiveness of interpretation
services;
support and enable patients and their families to advocate on their own behalf
when they experience discrimination in health and mental health care settings;
and
coach and/or mentor colleagues and staff to:
 implement a process of inquiry,
 address bias, and
 collaborate with communities.
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Facilitated Exercises and Activities
Exercise 1. Planning Language Services for Linguistically Diverse Groups
Note to faculty, trainers, and facilitator
Prior to engaging in this exercise, it would be helpful for the trainees to have available
the CLAS standards relating to the provision of linguistic services as well as the DHHS
Civil Rights Guidance on the provision of language services. These could be used as a
basis for preliminary discussion. This comprehensive exercise provides: 1) detailed steps
in developing a language plan and 2) opportunities to apply the language planning
process in 4 different scenarios.
Overview
In response to the DHHS Civil Rights regulations and CLAS standards, health and mental
health care organizations need to strategize how to best provide for the communication
preferences and needs of a diverse patient population. Each system or organization will
have different needs, based on the linguistic and cultural diversity of its service
population, geographic locale, proportion of these different groups, age distribution,
immigration status (immigrant, refugee, or asylee), and other demographic factors. Based
on these factors, systems and organizations need to devise a plan that will achieve high
quality of care and cost-effectiveness. Here are the steps:
Step 1. Assess the pattern of language preferences and needs in the service locales. This
pattern will include the number of different languages spoken, dialectal differences
within each language, and rank by frequency.
Step 2. Assess the points of service at which the most intense need for language services
occurs (in a hospital or clinic setting, this may be obstetrics and pediatrics). Assess the
points of service at which the most critical issues relating to language services occur, for
example, emergency or urgent care services, and intensive care.
Suggested Strategies for Implementing Steps 1 and 2
Department managers or supervisors can be tasked with oversight of this function.
Clinicians and others who are on the frontlines delivering services should be involved in
these activities and should review the findings for accuracy. Collaborators with key
stakeholders and constituents within the service are to (1) acquire local knowledge or
street-level information on patterns of in-migration and out-migration within
neighborhoods and communities, and (2) link with key informants within culturally and
linguistically diverse communities to ascertain information on dialectal differences and
local usage.
Step 3. Devise a language services plan that best meets the language preferences and
needs of the entire system or organization. First, it may be necessary to create for this
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purpose a group that includes key stakeholders, clinicians, and frontline staff. In other
instances, use existing community advisory committees or other structures to inform this
process. Give careful consideration to the most appropriate mix of the following:
 telephonic interpreting;
 contract interpreters provided by an outside agency or language bank;
 trained dual-role staff interpreters (considering the percentage of time they
should devote to interpreting and the burden on other staff members and their
supervisors, and also considering pay differentials for this added skill);
 dedicated trained and/or certified professional interpreters for specific languages
and locations of high need whose only job is to provide language services; and
 translation of signage, legal forms and related documents, and other written
materials.
Suggested Strategies for Implementing Step 3
Several resources, including Hablamos Juntos (www.hablamosjuntos.org) and The
California Endowment Web sites (http://www.calendow.org/), are available to assist with
planning processes. Additionally, the Commonwealth of Massachusetts Department of
Public Health has downloadable assistance for implementing internal procedures for
interpretation services at www.state.ma.us/dph. The Center for Applied Linguistics
(http://www.cal.org/) and the American Translators Associations
(http://www.atanet.org/) have general information on interpretation and translation.
Step 4. Devise a system for systematically allocating interpreters to different locations
within the system or organization, tracking telephonic and face-to-face interpreting times
and costs so that adjustments can be made as needed. Use itemized costs provided by
telephonic interpreting companies to monitor usage patterns and costs for each language
at each location or point of service.
Step 5. Assess professional development needs and preferences for both providers and
dual-role staff interpreters. Create a plan and allocate resources for ongoing training and
support.
Step 6. Create a quality improvement model that measures patient and provider
satisfaction with services and uses such data for modification and refinement.
Instructions for faculty, trainers, and facilitators
Solutions to meet the needs of service area populations vary dramatically across locales
and system or organizational characteristics. No one language services plan fits all
systems or organizations. This structured activity is designed to encourage analytical
thinking and creativity about optimal ways to meet the language preferences and needs of
diverse patient populations in different healthcare settings. Divide the participants into
several groups. Have each group create a language plan for one of the following
scenarios, keeping in mind the various ways of providing language services (i.e.
telephonic, dual-role interpreters, certified interpreters, a community interpreter bank).
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Scenario A. The Anderson Memorial Hospital, located in a large urban center, has a
service area in which the largest population group is African American (75%) followed
by Whites (20%). The population in the service area is predominantly low-moderate
income with a higher-than-average unemployment rate. The staff reflect the racial mix of
the population. Most staff are monolingual English speakers with the exception of 10
nurses and a receptionist who speak Tagalog, one pharmacist who speaks Japanese, and
janitorial staff who are mostly Spanish speakers. However, the service area is undergoing
rapid demographic changes: The African American population is declining and being
replaced by two Latino groups—individuals and families from Guatemala and El
Salvador.
Scenario B. La Clinica del Pueblo is located in a small Southwestern town. La Clinica
serves a population of migrant farm workers and their families (55% of the patient
population) from nearby rural areas, most of whom are Spanish-speaking Mexican
immigrants who work the migrant stream; a stable population of Native Americans who
live off-reservation (25% of the patient population); and the remaining 20% of the patient
population is white. Canning and flower-growing industries are enabling a sizeable group
of Mexican immigrants to settle permanently in the area. Dr. Ramirez, the medical
director, who is an internal medicine physician, has seen a large increase in the number of
the clinic’s patients with chronic lifestyle diseases, most notably diabetes. He and one
physician assistant speak Spanish fluently. The other four physicians and one Native
American nurse practitioner do not speak Spanish.
Scenario C. The state has decided to send all of its Medicaid patients into health
management organizations (HMO). The Medicaid population is highly diverse, both
linguistically and culturally. Many of the health management organizations have had
little experience in providing services to limited English speakers. The state Department
of Public Health has a contract with the State University to provide technical assistance in
developing a new language access plan that they will recommend to the HMO plans. The
contract requires an assessment of state demographics and languages used, creation of
standardized criteria for providing language services at various points of service, and cost
projections for the provision of these services. How would you approach these tasks?
Scenario D. A federally qualified community health center, which provides dental and
mental health services, has several sites serving urban and rural areas. Low-income white
populations primarily reside in the rural counties compared to more culturally and
linguistically diverse populations in the urban areas. Many languages other than English
are spoken by the patient population, but none of these languages are spoken by more
than 5% of the patient population. The most predominant languages are Urdu, Persian,
Somali, Korean, Vietnamese, Cantonese, and Spanish. One site has culturally diverse
Spanish-speaking physicians and nurses, and one site has a clinical psychologist who is
Korean American.
Page 40 of 73
Guidance for faculty, trainers, and facilitators
These questions are provided for all scenarios and are intended to assist faculty, trainers,
and facilitators in evaluating the comprehensiveness of the plans developed by the
trainees or students:

What was the level of involvement of the following in the planning process?
- system or organization policy makers and administrative staff
- frontline providers and staff
- community members and constituency groups
- patients and key stakeholders

What were the sources and methods of data collection?
- community and state demographics
- literacy levels

What data sources were used to determine quality and cost comparisons?

Does the plan comply with legal mandates governing language access?
Please see federal laws and guidelines related to language access in this module.

How well does the plan respond to the unique demographics and social-cultural
contexts of the given scenario?

Were there distinctions made between cultural group membership and language
ability (e.g., the Korean American physician may not speak Korean or the Spanishspeaking receptionist may not be Hispanic or Latino)?

To what extent did the plan address the consequences of changing demographics (e.g.
bias, discrimination, anger, resentment, fear of displacement, and conflict)?

What process and tools were used to determine professional development interests
and needs?

What quality improvement models were recommended?

Were participatory research design methodologies included in the approach to
evaluation of language services?
Page 41 of 73
Exercise 2. Understanding and Applying the Concept of Linguistic Competency
Step 1. The faculty, trainer, or facilitator reads aloud or posts the following definition of
linguistic competency.
Linguistic competence - the capacity of an organization and its personnel to communicate
effectively, and convey information in a manner that is easily understood by diverse
audiences including persons of limited English proficiency, those who have low literacy
skills or are not literate, and individuals with disabilities. Linguistic competency requires
organizational and provider capacity to respond effectively to the health literacy needs of
populations served. The organization must have policy, structures, practices, procedures,
and dedicated resources to support this capacity (Goode & Jones, 2004).
Step 2. Instruct the trainees/students to discuss the different components of the
definition, with instructor available for clarification.
Step 3. Divide the trainees/students into small groups in order to analyze and apply the
definition to each of the scenarios. Reconvene the groups to discuss their analyses of the
issues and the solutions to the problems presented in each scenario.
Scenario A. Your hospital received a complaint from the state Protection and Advocacy
Agency that several deaf patients were not provided with sign language interpretation
services. As a member of a task force convened to resolve this problem, what
recommendation would you make to the executive vice president of the hospital?
Scenario B. The state public health department hired a consultant to review their health
promotion and education materials. The consultant found that the majority of the
materials were written at a 12th-grade level and that none were available in languages
other than English. How should the public health department approach these findings?
(Check out the “Guide to Choosing and Adapting Culturally and Linguistically
Appropriate Health Promotion Materials” at
http://gucchd.georgetown.edu/nccc/documents/Materials_Guide.pdf.)
Scenario C. You are the clinical supervisor in a clinic that provides health and mental
health services in a large urban center. You observed patient intake staff denying
interpretation services to several families stating that, “You speak English, so you don’t
need a Spanish language interpreter.” As a supervisor, how would you approach this
problem with that particular staff member? How would you discover and address broader
systemic problems of which this one incident may be indicative?
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Scenario D. In response to the IOM’s report Health Literacy: A Prescription to End
Confusion (2004), a major health and mental health system convened a task force to
assess and recommend changes in its policy and practices related to health literacy. As a
task force member, you charged with researching the health literacy needs and
preferences of patients and communities served by the system. Rudd (2003) summarizes
the broad range of health literacy needs in health and mental health care settings, see
chart below.
How would you conduct this research?
Literacy Needs in Health & Mental Health Care
At a minimum, patients must be able to:











Access information
Recognize cues to action
Access care
Navigate institutions
Complete forms
Provide consent
Communicate with professionals
Provide information for assessment, diagnosis, & treatment
Understand directions
Follow regimens
Advocate
(from the PowerPoint presentation by Rima Rudd, at the Harvard School of Public
Health’s National Center for the Study of Adult Learning and Literacy, entitled “The
Challenges of Functional Health Literacy: A Role for Libraries” and retrieved May 17,
2005, from www.metro.org/SIGs/pdfs/chi_rudd_4_30_02.ppt). For additional
descriptions of the above points, see Powerpoint presentation by Wendy Jones based on
Dr. Rudd’s slide, click here (JR – please link to full text of Wendy’s powerpoint).
Guidance for faculty, trainers, or facilitators for scenario 4
 To what extent were community partners and stakeholders involved in the research?
 Was consultation sought from the system’s legal department?
 Were literacy needs and preferences in languages other than English considered?
 What fiscal and personnel resources were allocated for this research? Were members
from the community hired to assist in conducting the research?
 How will the research findings be disseminated or shared within the system? within
the communities?
(For information, see the Harvard School of Public Health’s Health Literacy site at
http://www.hsph.harvard.edu/healthliteracy/).
Page 43 of 73
Self-Discovery Exercise
Communication Styles
The following communication concepts represents a continuum. Read the paragraphs
that describe each end of the continuum, then place a mark that best describes where your
own communication style falls. Place another mark on the continuum that represents the
communication style that you find most difficult.
Degree of Directness
Direct
Indirect
<-------------------------------------------------------------->
People say what they mean and mean what they
People are indirect; they imply/suggest what they
say; you don't need to read between the lines;
mean; understatement is valued; you need to read
it's important to tell it like it is; honesty is the
between the lines; the truth, if it hurts, should be
best policy; the truth is more important than
tempered.
sparing someone’s feelings.
The Role of Context
Low Context
High Context
<-------------------------------------------------------------->
Low context, heterogeneous and individualist
cultures: little is already known; the message
must be explicit and spelled out; words are the
primary means of communication; non-verbal
cues are not the key to understanding.
High context, homogeneous and collectivist cultures:
much is already known; the spoken word is not the
primary means of communicating; much is implied
but little needs to be said; non-verbal cues and the
context are the key to understanding, what is not said
may be the message.
The Importance of Face
Face Less Important
Face Is Key
<-------------------------------------------------------------->
Face has moderate importance; the facts and
expediency are more important than being careful
about what you say; getting/giving information is
the overriding goal of the communication
exchange; criticism is straightforward; it’s okay to
say no, to confront people.
Face is paramount; saving face/not losing face
takes precedence over the “truth”; maintaining
harmony is the overriding goal of the
communication exchange; confrontation is
avoided; saying no is difficult; criticism is handled
very delicately; what one says and what one feels
often are not the same.
The Task and the Person
The Task
The Person
<-------------------------------------------------------------->
Page 44 of 73
The task is separated from the person; do business
first and then have small talk; establishing
rapport/good personal relationship is not essential
to getting the job done; the goal is accomplishing
the task.
The task and the person can’t be separated; begin
with small talk and then move to business;
personal relationship is a prerequisite to getting
the job done; the goal is building the relationship.
Guidance for faculty, trainers and facilitators
This exercise is designed to have trainees/students reflect on their individual
communication styles. It is important to emphasize that there are no value judgments
ascribed to any point on any continuum. Additionally, this exercise can be used to
uncover problems that trainees/students may have experienced in communicating with
others. Ask trainees/students to reflect on these experiences and to discuss the possible
perspectives and the communication styles of the other party or parties. Ask them how
these different communication styles might manifest themselves in interactions with: a)
patients or clients; b) colleagues; c) subordinates or supervisors; and d) community
members.
Adapted from the exercise found in “Culture Matters,” retrieved December 20, 2003,
from http://www.peacecorps.gov/wws/culturematters/Ch3/culturecomm.html
Other resources to aid self-discovery
Learning can be enhanced by both “reflection-on-action,” the practice of thinking back
on and analyzing past situations, and “reflection-in-action,” which consists of the practice
of applying past experiences and perspectives to new situations and being able to
continue to interact while making adjustments based on what one discerns about the
process. See the following resources for more information:
Schön, D. (1983). The reflective practitioner: How professionals think in action. New
York: Basic Books.
Westberg, J., & Jason, H. (2001). Fostering reflection and providing feedback: Helping
others learn from experiences. New York: Springer.
Page 45 of 73
Activity
Balint Group Discussions
Balint Groups have long been used to convene groups of health care professionals to talk
about specific patient encounters and the psychological and social factors involved. The
focus of the discussion is the health care provider’s relationship with the patient, the
patient’s family, and other members of the health care team. This group process lends
itself well to discussions of communication in a multicultural environment. The tools and
information in this module can be used as background for an exploration of cultural and
language factors in provider-patient interactions. Instructions on how to set up and
conduct Balint Group discussions can be found at http://familymed.musc.edu/balint/.
Page 46 of 73
TEACHING TOOLS
THE CASE AGAINST USING FAMILY, FRIENDS, AND MINORS
INTERPRETERS IN HEALTH AND MENTAL HEALTH CARE
SETTINGS
AS
Many systems and organizations continue the use of family, friends, and minors as
interpreters in the provision of health and mental health care. Unfortunately, this use
continues to be common practice in many settings. It is clearly far from evidence-based
and best practice, and may expose the system or organization to serious liability. This
discussion tool can be used to educate policy and decision makers, administrators,
providers, and the community at large about making the case against the use of family,
friends, and minors as interpreters for health and mental health care encounters.
Participants should be encouraged to share their own experiences related to the issues
raised in this tool.
Family Members and Friends as Interpreters
 Sometimes family members/friends are reluctant to ask questions when they do not
understand or when they are embarrassed. They may lack medical vocabulary in
English and their own language. Family members/friends are often uncomfortable
and will not ask for a more qualified interpreter when the situation gets beyond their
abilities.
Sometimes family members/friends will not give the patient a provider’s full and
complete explanations. They may be embarrassed to admit they do not
understand or embarrassed by the nature of the conversation. They might not agree
with the provider. Conversely, they may miscommunicate the patient’s message,
preferring that the provider hear their version of the situation.
 Family members’/friends’ emotional involvement often results in a tendency to
protect the patient from bad news; therefore, they edit or change information. Also,
sometimes family members/friends will not share with a provider the patient’s full
message, again because they are embarrassed, do not have what they judge to be the
proper vocabulary, or because they make a decision that the provider doesn’t need to
know “all this extra information.”
 Finally, aside from interpretation lapses, confidentiality is also a problem when
family members/friends serve as the interpreters. Often, the patient does not want to
disclose upsetting private information or secret issues in front of a relative. The
Page 47 of 73
patient may not feel confident that the family member/friend interpreter will maintain
confidentiality and will not disclose private information to others.
Minors or Children as Interpreters
The Office of Civil Rights, U.S. Department of Health and Human Services, expressly
discourages the use of minors in health care interpreting. The following tool provides a
selected list for the case against using children as interpreters:
 Role Reversal
The child ends up having to process information and provide help and
support to the parent or other adult.
 Editing
The child may interpret messages to suit his/her personal view of what is
appropriate, convenient, or proper to say to spare parents from suffering
embarrassment.
 Mistakes
It is unlikely that children understand all the intended messages, even when they
say (and believe) they do.
 Guilt
It is easy for children to feel they are the cause of suffering because they said
something painful or made a mistake in conveying a message.
 Omissions
Adult patients often omit mentioning important information because they do not
want the child to know sensitive aspects of their lives.
 Confidentiality
Even when cautioned, children do not understand issues of confidentiality and
may inadvertently reveal sensitive material learned during interpreting.
In addition to those reasons cited above, there may be religious, spiritual, and moral
prohibitions against engaging minor children in adult situations and discussions (e.g.,
sexual practices, reproductive health, substance use and abuse, and domestic violence).
Page 48 of 73
TEACHING TOOLS
THE CASE AGAINST USING UNTRAINED INTERPRETERS
Interpreting in health and mental health care requires the development of special
interactive skills and a high degree of proficiency in both languages. For example, the
knowledge set required of interpreters is to be familiar with not only a standard use of
language, but also the dialectal variations of language used within the community,
including colloquialisms and slang. Interpreters also must be aware of confidentiality
requirements both as a matter of ethical conduct and as health and mental health care
regulations.
The use of untrained interpreters is fraught with potential problems for the patient and the
health or mental health care organization. A selected list of problems that will serve as a
basis for discussion is provided below.
Untrained Interpreters
 Lack of Translatable Words/Concepts
Similar words do not exist in the two languages; the interpreter is not proficient
enough in either language to find an accurate substitute.

Deletion of Information
The interpreter cannot keep up with the exchange and paraphrases or leaves out
concepts.
 Modification of Meaning
The interpreter may not understand what is said, so substitutes what he or she
thinks was said, often changing the meaning substantially.
 Unfamiliar Terminology
The interpreter is unfamiliar with medical, health, or mental health terminology,
perhaps in both languages.
 Changes in Register
The interpreter alters more formal language into colloquial or just the opposite.
 Embarrassment
The interpreter is not clinically trained and may become embarrassed while
interpreting discussions of sexual issues, body functions, and other sensitive
information.
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 Deliberate Editing of Information
The interpreter may attempt to control or alter the flow of information from one or
both parties for his or her own purposes. This editing occurs through both addition
and deletion of words or even whole messages.
 Emotional Issues
The interpreter may be too close to the patient or not emotionally equipped to be
able to deal with discussions of severe illness or disorders, serious medical
situations, or end-of-life concerns.
 Confidentiality
The interpreter does not understand the need for confidentiality or is not bound by
professional standards.
Page 50 of 73
TEACHING TOOLS
GENERAL GUIDELINES FOR PROVIDERS USING INTERPRETERS
IN HEALTH AND MENTAL HEALTH CARE SETTINGS
Unless providers are thoroughly fluent in the patient’s language, it is strongly
recommended that they work with a trained interpreter. In this way, providers know that
their patients fully understand the diagnosis, treatment, instructions, or advice and that
the providers know that they understand patients’ description of their illness and concerns
as completely as possible. If providers have limited knowledge of a language, they can
use their skills to establish rapport and express their respect (e.g., greetings and informal
exchanges).
Be aware of patient barriers to requesting interpreter services
Patients may not ask for an interpreter because they:

may be shy or fear appearing too demanding;

do not want to appear stupid or uneducated;

are unaware of their legal rights as mandated under Title VI and other statutes;

fear seeming disrespectful or seeming to call into question a provider’s linguistic
expertise;

may be afraid of losing face by showing ignorance of medical terminology or
unfamiliarity with the way health care is structured in the United States;

may be concerned that it will cost them extra money; and

may be worried about confidentiality issues.
As a provider, if you suspect that patient care would be enhanced by using an interpreter,
it is incumbent upon you to encourage getting an interpreter and to advocate for, and even
insist on, services. Many patients prefer a same gender interpreter, particularly when a
physical examination is to take place. This preference may require a level of
sophistication that the system lacks, so it is important that providers advocate for this.
If you are working for the first time with a trained interpreter, you will need to agree on
how you will work together as a team. If you consistently work with the same trained
interpreter, your team style will soon become automatic.
Page 51 of 73
The all-important pre-encounter briefing

Tell the interpreter what you hope to accomplish, what the encounter is about.
This is necessary in all but the most routine patient visits. Preferably, do this out
of the hearing of the patient.

Ask the interpreter if he or she is familiar with the concepts involved.

Reach consensus with the interpreter on interpretation techniques (e.g., how the
interpreter can signal you to pause or show that he or she needs to stop to explain
something the patient has said).

Reach consensus with the interpreter about use of first- or third-person mode of
interpreting. If first person is used, the interpreter speaks as each speaker
alternately, using the pronoun “I.” Using the first person, although initially more
difficult, improves the accuracy of the interpretation.

Point out the importance of accuracy, completeness, impartiality, and especially
confidentiality when working with non-staff and staff interpreters. Encourage,
interpreters to ask questions when they are uncertain.

Encourage interpreters to make pertinent comments when they notice a
conceptual or linguistic misunderstanding occurring. If the interpreter is familiar
with, or from the same cultural group as, the patient, he or she may notice cultural
misunderstandings as well.

Insist that the interpreter interpret everything that is said by you or by the patient.
During the interpreted encounter

Be sure to introduce the interpreter to the patient if unknown to the patient.
Emphasize that the interpreter is bound by patient-provider confidentiality just as
you are.

Ask the interpreter to place himself or herself slightly to one side and behind the
patient, so that it is easy to look directly at the patient when the interpreter is
speaking.

Look at the patient, not the interpreter. The interpreter should be viewed only as a
conduit. Observe non-verbal signs that will give you an indication of the patient’s
emotional affect; this will provide you with important information.

Express one concept at a time. Avoid using contractions, acronyms, or jargon.
Provide a brief explanation of technical terms if they cannot be avoided.
Page 52 of 73

Pace your speech so that the interpreter and the patient can understand and follow
it.

Make sure the complexity of the language is not beyond the interpreter’s medical,
health, or mental health care knowledge and familiarity with institutional
protocols and procedures.

Speak slowly, enunciate clearly, and avoid using medical, health, or mental health
care jargon or American slang. When the interpreter finishes explaining a point to
the patient, occasionally ask the interpreter to tell you in English exactly what he
or she just told the patient. This “re-telling” will give you the feedback you need
to feel confident about the quality of the translation or to identify and catch
mistakes.
Debriefing the interpreted encounter
Ask for feedback from the interpreter. If possible after the interview, speak privately with
the interpreter. Interpreters from the same cultural group of the patient may perceive
cultural and emotional subtleties more clearly than you. Take advantage of their unique
bicultural or multicultural perspectives. Be open to comments.
Teamwork
It is helpful for providers to meet with staff or contract interpreters periodically to refine
their mutual working methods and strategies. Discuss the techniques that are working
well and those that need to be improved. In many instances, interpreters also can give
providers important background on the language and culture of patients. In these
instances, the interpreter is acting in the role of cultural broker (see Bridging the
Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker
Programs at
http://gucchd.georgetown.edu/nccc/documents/Cultural_Broker_Guide_English.pdf). A
much more comfortable working relationship will develop if interpreters are openly
recognized as an important part of the health and mental health care team and are clearly
valued for their contribution to high-quality patient care.
Page 53 of 73
Selected Resources for Process of Inquiry—Communicating in a Multicultural
Environment Module
Video Resources
Disability is Natural
This video is used as a training tool for a wide audience, including parents, people with
disabilities and their families, policy makers, and providers. According to their Web site,
“the messages in this video question today’s conventional wisdom, pose provocative
questions, and describe positive scenarios that can occur when we realize disability is
natural. The combination of these revolutionary ideas coupled with the inspirational
music create an unforgettable experience.” See
http://www.disabilityisnatural.com/store/index.html
Quality Interactions: A Patient-Based Approach to Cross-Cultural Care
The Manhattan Cross Cultural Group, a training and research organization headed by
three physicians, Joseph Betancourt, Emilio Carrillo, and Alexander Green, has
developed an interactive, 2-hour e-learning course, Quality Interactions: A Patient-Based
Approach to Cross-Cultural Care. Based on curricula taught at several leading medical
centers, the course allows users to obtain continuing medical education credits. It
responds directly to the recommendations of the IOM reports Unequal Treatment and
Crossing the Quality Chasm. The course is being made available by Critical Measures,
LLC, at www.criticalmeasures.net.
That’s Not What I Meant: Language, Culture, and Meaning
Two videos presenting content on language, culture, and resolving misunderstanding. See
http://www.georgetown.edu/faculty/tannend/videos.htm#Thats_Not_What_I_Meant_Lan
guage.
Videos From Kaiser Permanente
Kaiser Permanente, in collaboration with The California Endowment, has developed a set
of 20 trigger videos that focus on a variety of issues in cross-cultural communication with
patients in a variety of clinical settings. The topics include problems encountered in using
untrained interpreters, initial clinician reluctance to use telephonic interpreting,
communication around sensitive issues such as domestic abuse, gestational diabetes,
prostate exams, sexually transmitted diseases (STDs), gay adolescents, alternative
medicine use, literacy, somatization, end-of-life decision making, and traditional folk
medical practices and concepts of healing. Each video is accompanied by contextual
background materials and a facilitator’s guide for debriefing the video. Each trigger video
and materials can be used for a training session of 30–45 minutes.
The set of 20 trigger videos and accompanying materials sells for $105. For information
and order forms, contact Gus Gaona at (323) 259-4776 or by mail:
Gus Gaona, Kaiser Permanente National Video Communications and Media Services,
825 Colorado Boulevard, #301, Los Angeles, CA 90041.
Page 54 of 73
Video (VHS or DVD)
In Plain Language: The Need for Effective Communication in Medicine and Public
Health, http://ncsall.gse.harvard.edu/video.html, from the National Center for the
Study of Adult Learning and Literacy (NCSALL).
Internet Resources
An Overview of Empathy (2003), by J. T. Hardee, The Permanente Journal (2003).
Retrieved March 31, 2005, from
http://xnet.kp.org/permanentejournal/fall03/cpc.html
Communicate to Make a Difference: Exploring Cross-Cultural Communication,
a free, online course designed for public health professionals, hosted by the New
York and New Jersey Public Health Training Center. To register, see
http://www.nynj-phtc.org/cc/default.cfm
Communicating with Patients, A Quick Reference Guide for Clinicians, Association of
Reproductive Health Professionals. Retrieved March 31, 2005, from
http://www.arhp.org/healthcareproviders/onlinepublications/QRGPACC.cfm
Health…in brief (on language access strategies in California with examples from other
states) (2003), The California Endowment, at
http://www.calendow.org/reference/publications/pdf/cultural/Language_HIB03.pdf
Partnership for Clear Health Communication, see www.askme3.org/PFCHC
The Principles and Recommended Standards for Cultural Competence Education of
Health Care Professionals (2003), M. Jean Gilbert, Editor, and A Manager’s Guide
to Cultural Competence Education for Health Care Professionals (2003), M. Jean
Gilbert, Editor.
The California Endowment, www.calendow.org has made available two
downloadable resources cited above, edited by M. Jean Gilbert, to aid health care
organizations in determining appropriate training and curricula for the cultural
competence education of
health care professionals. See
http://www.calendow.org/reference/publications/cultural_competence.stm
Tips for Talking: A Guide to Inclusive Communication for Physicians, Medical Students,
and Educators (1997), by Sophia Lee, Lucia Beck Weiss, and Sandra P. Levison,
Women’s Health Education Program, see
http://webcampus.med.drexel.edu/whep/tipstalking.htm
Working on Common Cross-cultural Communication Challenges, by Marcelle DuPraw,
National Institute for Dispute Resolution, and Marya Axner, Consultant in
Leadership Development & Diversity Awareness. See
www.wwcd.org/action/ampu/crosscult.html
Page 55 of 73
Print Resources
A Strategy To Reduce Cross-Cultural Miscommunication and Increase the Likelihood of
Improving Health Outcomes (2003), by M. Kagawa-Singer and S. Kassim-Lakha,
Academic Medicine, Volume 78, No. 6, 577–587.
Culture and Parental Expectations for Child Development: Critical Concerns for
Language Development and Early Learning, edited by S. Rosenkoetter and J.
Knapp-Philo. In Learning to Read the World: Language and Literacy in the First
Three Years (2005), by W. Jones and I. Lorenzo-Hubert. Washington: Zero to
Three Publishing.
Health Communication in Practice: A Case Study Approach (2005), edited by E. B. Ray.
Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Improving Chronic Disease Care in the Real World: A Step-by-Step Approach (1999,
October), by B. White. Family Practice Management, 38–43.
See http://www.aafp.org/fpm/991000fm/38.html
Intercultural Communication (2001), by F. E. Jandt. Thousand Oaks, CA: Sage.
Marrying Content and Process in Clinical Method Teaching: Enhancing the CalgaryCambridge Guides (2003), by S. Kurtz, J. Silverman, J. Benson, and J. Draper,
Academic Medicine, Volume 78, No. 8, 802–809. See
http://www.academicmedicine.org/cgi/content/full/78/8/802
Orality and Literacy: The Technologizing of the Word (1988), by W. J. Ong. (New
Accents Series). New York: Methuen.
That’s Not What I Meant: How Conversational Style Makes or Breaks Relationships
(1987), by D. Tannen. New York: Ballantine Books.
The Development of Language (2005), by J. Gleason. (6th ed.). New York: Allyn and
Bacon.
The Role of Culturally Competent Communication in Reducing Ethnic and Racial
Healthcare Disparities (2004), by S. L. Taylor and N. Lurie. American Journal of
Managed Care, 10 Spec No: SP1-4.
Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies
(2002), by S. Mutha, C. Allen, and M. Welch. San Francisco: Center for the Health
Professions, University of California, San Francisco.
Understanding Misunderstanding: Barriers to Dealing with Diversity (1989), by K.
Cushner, and G. Tifonovitch, Social Education, Volume 53, No. 5, 318–322.
Page 56 of 73
Resources on Communication and Disabilities
Internet Resources
Accessible Web design from the U.S. Department of Health and Human Services at
http://www.usability.gov/
Administration on Developmental Disabilities
See http://www.acf.dhhs.gov/programs/add/
American Speech-Language-Hearing Association
See http://www.asha.org/default.htm
Association of University Centers on Disability
See http://www.aucd.org/
Center for Spoken Language Understanding
http://cslu.cse.ogi.edu/general/whatiscslu.html
Disability Etiquette, in .pdf format, by the United Spinal Association, at
http://www.unitedspinal.org/pages.php?catid=7&pageid=472
Disability Etiquette from Easter Seals at
http://www.easterseals.com/site/PageServer?pagename=ntl_etiquette
Disability Etiquette Handbook, including communication tips, from the City of San
Antonio, Texas, Planning Department and the Disability Advisory Committee at
http://www.sanantonio.gov/planning/disability_handbook/disability_handbook.asp?
res=1280&ver=true
Guidelines for Professionals Dealing With Persons With Intellectual Disabilities from the
American Association on Mental Retardation at
http://www.aamr.org/Policies/guidelines.shtml
Health & Wellness links for people with disabilities
http://www.allabilities.com/health.html
National Institute on Disability and Rehabilitation Research
See http://www.ed.gov/about/offices/list/osers/nidrr/index.html?src=mr
Oregon Health & Science University, Oregon Institute on Disability and Development,
University Center for Excellence in developmental disabilities education, research,
and service. See http://www.oidd.org/
People First Language, a Web article by Kathie Snow. Retrieved April 22, 2005, from
http://www.disabilityisnatural.com/peoplefirstlanguage.htm
Page 57 of 73
The American Indian Disability Technical Assistance Center at
http://aidtac.ruralinstitute.umt.edu
The Memphis Center for Independent Living has a Web site with etiquette,
communication, and relationship-building tips at
http://www.mcil.org/mcil/mcil/etiqu01.htm
The Rehabilitation Research and Training Center: Health & Wellness has a newsletter
available as well as information and links from
http://www.healthwellness.org/whatsnew/newsletters.htm
The Research and Training Center on Disability in Rural Communities at
http://rtc.ruralinstitute.umt.edu
University of Montana Rural Institute’s Food On Film (copyright), refined the 24-hour
diet recall method to include the use of still photographs. This method is potentially
useful for nutrition professionals working with any population in which cognitive or
communication barriers affect the quality of food intake assessments. See
http://mtdh.ruralinstitute.umt.edu/Publications/FoodonFilm.htm
Print Resources
Culturally Competent Professionals in Therapeutic Alliances Enhance Patient
Compliance (1999, February), by N. Langer, Journal of Health Care for the Poor
and Underserved, Volume 10, No. 1, 19–26.
L’Institut Roeher
See http://www.roeher.ca, which includes the publication:
Literacy, Disability and Communication: Making the Connection (1999), by
L’Institut Roeher. York University, Toronto, Ontario: L’Institut Roeher.
Resources on Translation & Interpretation
California Pan-Ethnic Health Network (CPEHN) has made access to quality translation
and interpretation a priority area. See http://www.cpehn.org/whatwedo.php.
CPEHN wrote a policy brief in December 2004, entitled Limited English Proficient
Enrollee Access to Health Plan Grievance Systems, which documents problems and
offers solutions. This report is available for download directly from
http://www.cpehn.org/policybriefs.php
Hablamos Juntos provides many resources at
http://www.hablamosjuntos.org/resources/default.resources.asp
Page 58 of 73
Language Access: Giving Immigrants a Hand in Navigating the Health Care System,
from the National Conference of State Legislatures. See
http://www.ncsl.org/programs/immig/SHNarticle.htm
Quality of Care for Underserved Populations, a program area of The Commonwealth
Foundation that offers resources on language services, including Providing
Language Services in Small Health Care Provider Settings: Examples from the Field
(Youdelman & Perkins, 2005), available from the program Web site at
http://www.cmwf.org/programs/programs_list.htm?attrib_id=9133 or directly from
http://www.cmwf.org/usr_doc/810_Youdelman_providing_language_services.pdf
Thoughts on Live vs. Telephone and Video Interpretation (1997), by Ines Swaney,
Proteus, Volume 6, No. 2. See http://www.najit.org/proteus/back_issues/swaney.htm
What a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with
Limited English Proficiency, a report by The Access Project, available at
http://www.accessproject.org/camspublications.htm
Print or Other Resources
National Coalition for Quality Translations in Health Care, formed in 2004 by Kaiser
Permanente’s National Linguistic & Cultural Programs of National Diversity. For
additional information, contact Gayle Tang at (510) 271-6386 or Sunny Pak at (510)
271-6868 or call National Diversity hotline at (510) 271-6663.
Pay Now or Pay Later: Providing Interpreter Services in Health Care (2005), by L. Ku
and G. Flores, Health Affairs, Volume 24, No. 2, 435–444.
Language and Health
Language Services Access Kit (2003), developed by the National Health Law Program
and The Access Project. See http://www.accessproject.org/projects.htm
Overcoming language barriers to health care (1999), by Jane Perkins, Popular
Government, Volume 65, No. 1, 38–44. See https://iogpubs.iog.unc.edu/ for viewing
or ordering information.
Policy Fact Sheet on Persons with Limited English Proficiency (2003), The Association
of Asian Pacific Community Health Organizations. See
http://www.aapcho.com/links/policypaper2003LEP.pdf
Summary Brief from Hablamos Juntos on providers’ perspective regarding the health
impact of language barriers. See
http://www.hablamosjuntos.org/resourcecenter/pdf/00606272003.pdf
Page 59 of 73
Literacy Resources
Internet-Based Resources
Addressing health literacy: A description of the intersection of functional literacy and
health care (2001), by David Foulk, American Journal of Health Studies, Volume
17.1. Pdf download available at no cost as retrieved on April 14, 2005, see
http://ajhs.tamu.edu, past issues.
An updated overview of medical and public health literature addressing literacy issues:
An annotated bibliography of articles published in 2000, by J. Greenberg, Harvard
School of Public Health, National Center for the Study of Adult Learning and
Literacy. Retrieved April 8, 2005, from
http://www.hsph.harvard.edu/healthliteracy/annotations.html
California Literacy Web site with resources on health literacy at
http://www.caliteracy.org/healthliteracylinks.html
Functional health literacy: Improving health outcomes (2004, May 1), by Allen Hixon,
American Family Physician, Volume 69, No. 9. Available online at
http://www.aafp.org/afp/20040501/medicine.html
Harvard’s Health Literacy Studies page
http://www.hsph.harvard.edu/healthliteracy/
Health literacy and interpretation: An issue of cultural competence, by Francesca Gany,
Alexis Rourk, Ephraim Shapiro, and Abraham Aragones. A paper presented on
November 10, 2004, at the American Public Health Conference, “Public Health and
the Environment,” description and learning objectives online at
http://apha.confex.com/apha/132am/techprogram/paper_88377.htm
Health literacy beyond basic skills (2003), by Sandra Kerka. ERIC Digest. Columbus,
OH: ERIC Clearinghouse on Adult Career and Vocational Education.
http://www.ericdigests.org/2004-1/health.htm
Literacy and Health in America, available for download directly from
http://www.ets.org/research/pic/literacy&health.pdf or purchase copies for $15
(prepaid) by writing to the Policy Information Center, ETS, MS 19-R, Rosedale
Road, Princeton, NJ 08541-0001; by calling (609) 734-5694; or by sending an e-mail
to pic@ets.org
Literacy and Health Outcomes (2004, January), from the Agency for Healthcare
Research and Quality, see http://www.ahrq.gov/clinic/, under Evidence-Based
Practice; Quality Improvement and Patient Safety or summary at
http://www.ahrq.gov/clinic/epcsums/litsum.htm
Page 60 of 73
Print Resources
Health Literacy: A Prescription to End Confusion (2004), from the Institute of Medicine,
National Academy Press. To order, see http://www.nap.edu/catalog/10883.html
Literacy and Health in America (2004), by R. E. Rudd, I. Kirsch, and K. Yamamoto.
Princeton, NJ: Educational Testing Services.
Resources on Social Context, Culture, Health, and Mental Health
Print Resources
Actual Causes of Death in the United States, 2000 (2004, March 10), by A. H. Mokdad,
J. S. Marks, D. F. Stroup, and J. L. Gerberding, Journal of the American Medical
Association, Volume 291, No. 10, 1238–1245.
Belief and Narrative: An Understanding Of Pain, Bereft of Its Cultural Dimensions, Is
Woefully Incomplete (2005, March 28), by David B. Morris, The Scientist, Volume
19, Supplement 1.
From Neurons to Neighborhoods: The Science of Early Childhood Development (2000),
by the Institute of Medicine. National Academy Press: Washington, DC.
Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences
(2001), by the Institute of Medicine. National Academy Press: Washington, DC.
The Illness Narratives: Suffering, Healing and the Human Condition (1988), by Arthur
Kleinman. New York: Basic Books.
The Meaning of Illness: A Phenomenological Account of the Different Perspectives of
Physician and Patient (1992), by S. K. Toombs, Philosophy and Medicine Series,
Volume 42. Dordrecht, The Netherlands: Kluwer Academic Publishers.
Understanding the Environmental Issues in Diabetes Self-Management
Education Research: A Reexamination of 8 Studies in Community-Based Settings
(2004), by Leonard Jack, Jr., Leandris Liburd, Tirzah Spencer, & Collins O.
Airhihenbuwa. Annals of Internal Medicine, 140(11), 964–971.
Process of Inquiry—Communities
Internet-Based Resources
Collaborative Solutions—Engaging the Community (2005, Winter), a newsletter from
Tom Wolff & Associates, available from http://www.tomwolff.com/
Page 61 of 73
Relationships of a Brief Measure of Youth Assets to Health-Promoting and Risk
Behaviors (2004, March), by D. A. Murphey, K. H. Lamonda, J. K. Carney, and P.
Duncan, Journal of Adolescent Health, Volume 34, No. 3, 184–191.
The Wingspread Symposium: Involving Young People in Community Evaluation
Research (2003, Spring), by Barry Checkoway, David Dobbie, and Katie RichardsSchuster, Community Youth Development Journal, Volume 4, No. 1. See
http://www.cydjournal.org/2003Spring/checkoway.html
Youth Participation in Public Policy at the Municipal Level (2005), by B. Checkoway, T.
Allison, and C. Montoya, Children and Youth Services Review. See
www.elsevier.com/locate/childyouth or see
http://closup.umich.edu/research/funded/mpp/youth-participation.html
Print Resources
Culturally Competent Diabetes Self-Management Education for Mexican Americans:
The Starr County Border Health Initiative (2002, February), by S. A. Brown, A. A.
Garcia, K. Kouzekanani, and C. L. Hanis, Diabetes Care, Volume 25, No. 2, 259–
268.
Developing Local Public Health Capacity in Cultural Competency: A Case Study With
Haitians in a Rural Community (2004, December), by L. D. Phelps and K. E.
Johnson, Journal of Community Health Nursing, Volume 21, No. 4, 203–215.
Page 62 of 73
Appendix
Summary of DHHS Guidance from www.hhs.gov/ocr/lep/guide.html

Federal fund recipients should have a written language services policy and should
disseminate it widely throughout the organization.

Interpreter/translation services should be offered at no cost to individuals with limited
English proficiency.

Organizations should identify a person or department with accountability for language
services.

Health care organizations should have a system for tracking patients’ language needs,
monitored and periodically reviewed.

Organizations should notify patients of the availability of no-cost language services
through signage, rights and responsibilities, membership materials, and non-English
media.

Family members and friends should be asked to provide interpreter services only
after alternative, no-cost methods have been explained and the patient so chooses.
This decision must be recorded in the patient chart.

Minors should not be used to interpret.

Federally funded organizations need to ensure the availability of interpreters on a
24-hour basis or during all hours of operation.

Interpreters should be qualified and trained, demonstrating proficiency in both
languages. Interpreter skills should be evaluated on an ongoing basis.

Telephone interpretation should be used for rare languages and when interpreters are
unavailable.

Organizations should have translated written materials available.
Page 63 of 73
Corollary to and supporting the DHHS language services guidelines are CLAS standards,
which are available at the following Web site: www.omhrc.gov/clas/finalcultural1a.htm.
Standards 4, 5, 6, and 7 deal specifically with language services:
4. Health care organizations must offer and provide language assistance services,
including bilingual staff and interpreter services, at no cost to each patient/consumer with
limited English proficiency at all points of contact, in a timely manner during all hours of
operation.
5. Health care organizations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to receive
language assistance services.
6. Health care organizations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters and bilingual
staff. Family and friends should not be used to provide interpretation services (except on
request by the patient/consumer).
7. Health care organizations must make available easily understood patient-related
written materials and post signage in the languages of the commonly encountered group
and/or groups in the service area.
Page 64 of 73
References used to prepare this module
Agency for Healthcare Research and Quality (2004, April 8). New Evidence Report
Illustrates Links Between Health Literacy and Health Care Use and Outcomes.
Press Release. Rockville, MD: Author. Retrieved April 8, 2005, from
http://www.ahrq.gov/news/press/pr2004/litpr.htm
Bade, K. R., Murphy, J., & Sullivan, M. C. (1999). Lessons from the field—health care
experiences and preferences in a Latino community. Bioethics Forum. 15(4) 33–42.
Baker, D. W., Parker, R. M., Williams, M. V., Coates, W. C., & Pitkin, K. (1996). Use
and effectiveness of interpreters in an emergency department. Journal of the
American Medical Association, 275(10), 783–788.
Barrier, P. A., Li, J.T., & Jensen, N. M. (2003, February). Two words to improve
physician-patient communication: What else? Mayo Clinic Proceedings, 78(2),
211–214. (Review)
Beck, R. S., Daughtridge, R., & Sloane, P.D. (2002, January/February). Physician-patient
communication in the primary care office: A systematic review. The Journal of the
American Board of Family Practice, 15(1), 25–38.
Bell, J., & Standish, M. (2005). Communities and health policy: A pathway for change.
Health Affairs (Millwood), 24(2), 339–342.
Berlin E., & Fowkes, W. (1983). A teaching framework for cross-cultural health care.
Western Journal of Medicine, 139, 934–938.
Berry, D. L., Wilkie, D. J., Thomas, C. R., Jr., Fortner, P. (2003, June). Clinicians
communicating with patients experiencing cancer pain. Cancer Investigation, 21(3),
374–381. (Review)
Bowen, L. K., Gwiasda, V., & Brown, M. M. (2004). Engaging community residents to
prevent violence. Journal of Interpersonal Violence, 19(3), 356–367.
Brown, R., Bratton, S. L., Cabana, M. D., Kaciroti, N., & Clark, N. M. (2004, August).
Physician asthma education program improves outcomes for children of lowincome families. Chest, 126(2), 369–374.
Brach, C., Fraser, I., & Paez, K. (2005, March/April). Crossing the language chasm.
Health Affairs, 24(2), 424–434.
Burbano O’Leary, S. C., Federico, S., & Hampers, L. C. (2003). The truth about language
barriers: One residency program. Pediatrics, 111(5), 569–573.
Page 65 of 73
Campbell, P., U.S. Census Bureau (1997). Population projections: States, 1995–2025,
published May 1997,
http://www.census.gov/population/www/projections/stproj.html
Carrasquillo, O., Orav, E. J., Brennan, T. A., & Burstin, H. R. (1999, February). Impact
of language barriers on patient satisfaction in an emergency department. Journal of
General Internal Medicine, 14(2), 82 –87.
Chene, R., Garcia, L., Goldstrom, M., Pino, M., Roach, D. P., Thunderchief, W., &
Waitzkin, H. (2005). Mental health research in primary care: Mandates from a
community advisory board. Annals of Family Medicine, 3(1), 70–72.
Committee on Language, American Speech-Language-Hearing Association. (1983).
Definition of language. ASHA, 25, 44.
Comstock, L. M., Hooper, E. M., Goodwin, J. M., & Goodwin, J. S. (1982, February).
Physician behaviors that correlate with patient satisfaction. Journal of Medical
Education, 57(2), 105–112.
Cornelio, M. (2004). Quality translation in health care: Kaiser Permanente—Meeting the
challenge. Apuntes, 12(4), 14–15. See http://spansig.org/Translation/KP.pdf
DiMatteo, M. R. (1995, October). Patient adherence to pharmacotherapy: The importance
of effective communication. Formulary, 30(1), 596–598, 601–602, 605.
Dube, C. E., O’Donnell, J. F., & Novack, D. H. (2000, July). Communication skills for
preventive interventions. Academic Medicine, 75(7 Suppl), S45 –S54.
Duffy, F. D., Gordon, G. H., Whelan, G., Cole-Kelly, K., Frankel, R., Buffone, N.,
Lofton, S., Wallace, M., Goode, L., Langdon, L., & Participants in the American
Academy on Physician and Patient's Conference on Education and Evaluation of
Competence in Communication and Interpersonal Skills. (2004, June). Assessing
competence in communication and interpersonal skills: The Kalamazoo II report.
Academic Medicine, 79(6), 495–507. (Review)
Duranti, A. (1997). Linguistic anthropology. Cambridge: Cambridge University Press.
Faust, L. A., Blanchard, L. W., Breyfogle, D. A., Baroni, J. K., Reed, R. E., & Young, M.
J. (2005). Discussion suppers as a means for community engagement. Journal of
Rural Health, 21(1), 92–95.
Flores, G., Laws, B., Mayo, S., Zuckerman, B., Abreau, M., Medina, L., & Hardt, E.
(2003). Errors in medical interpretation and their potential clinical consequences in
pediatric encounters. Pediatrics, 111(1), 6–14.
Frankel, R. M., & Stein, T. (1999). Getting the most out of the clinical encounter: The
Four Habits Model. The Permanente Journal. Retrieved March 31, 2005, from
http://xnet.kp.org/permanentejournal/fall99pj/habits.html
Page 66 of 73
Frymoyer, J. W., & Frymoyer, N. P. (2002, March/April). Physician-patient
communication: A lost art? The Journal of the American Academy of Orthopaedic
Surgeons, 10(2), 95–105.
Gazmararian, J. A., Curran, J. W., Parker, R. M., Bernhardt, J. M., & Debuono, B. A.
(2005, April). Public health literacy in America: An ethical imperative. American
Journal of Preventive Medicine, 28(3), 317–322.
Gjerde, C. L., Kokotailo, P., Olson, C. A., & Hla, K. M. (2004, January). A weekend
program model for faculty development with primary care physicians. Family
Medicine, 36(Suppl), S110–S114.
Goode, T. (2001). Policy Brief 4: Engaging communities to realize the vision of one
hundred percent access and zero health disparities: A culturally competent
approach. Washington, DC: National Center for Cultural Competence, Georgetown
University Child Development Center.
Goode, T. D. (1989, June, revised 1993, 1996, 1997, 1999, 2000, 2002, and 2004).
Promoting Cultural and Linguistic Competency Self-Assessment Checklist for
Personnel Providing Primary Health Care. Adapted from Promoting cultural
competence and cultural diversity for personnel providing services and supports to
children with special health care needs and their families. Washington, DC:
Georgetown University Center for Child and Human Development.
Goode, T., & Jones, W. (2003, revised 2004). Definition of linguistic competence.
Washington, DC: National Center for Cultural Competence, Georgetown University
Center for Child and Human Development.
Goode, T., Sockalingam, S., Brown, M., & Jones, W. (2000, revised 2003). Linguistic
competence in primary health care delivery systems: Implications for policy
makers. Washington, DC: National Center for Cultural Competence, Georgetown
University Child Development Center.
Hausman, A. (2001). Taking your medicine: Relational steps to improving patient
compliance. Health Marketing Quarterly, 9(2), 49–71.
Hausman, A. J., Brawer, R., Becker, J., Foster-Drain, R., Sudler, C., Wilcox, R., & Terry,
B. J. (2005). The Value Template Process: A participatory evaluation method for
community health partnerships. Journal of Public Health Management and
Practice, 11(1), 65–71.
Heisler, M., Bouknight, R. R., Hayward, R. A., Smith, D. M., & Kerr, E. A. (2002,
April). The relative importance of physician communication, participatory decision
making, and patient understanding in diabetes self-management. Journal of General
Internal Medicine, 17(4), 243–252.
Hornberger, J., Itakura, H., & Wilson, S. R. (1997). Bridging language and cultural
barriers between physicians and patients. Public Health Reports, 112(5), 410–417.
Institute of Medicine. (2001). Health and behavior: The interplay of biological,
behavioral, and societal influence. Washington, DC: National Academy Press.
Page 67 of 73
Institute of Medicine. (2004). Health literacy: A prescription to end confusion.
Washington, DC: National Academy Press.
Institute of Medicine. (2002). Speaking of health: Assessing health communication
strategies for diverse populations. Washington, DC: National Academy Press.
Jacobs, E. A., Lauderdale, D. S., Meltzer, D., Shorey, J. M., Levinson, W., & Thisted, R.
A. (2001). Impact of interpreter services on delivery of health care to limitedEnglish-proficient patients. Journal of General Internal Medicine, 16, 468–474.
Kaplan, S. H., Greenfield, S., Gandek, B., Rogers, W. H., & Ware, J. E., Jr. (1996, March
1). Characteristics of physicians with participatory decision-making styles. Annals
of Internal Medicine, 124(5), 497–504.
Karliner, L. S., Perez-Stable, E. J., & Gildengorin, G. (2004). The language divide: The
importance of training in the use of interpreters for outpatient practice. Journal of
General Internal Medicine, 19(2), 175–183.
Karter, A. J., Ferrara, A., Darbinian, J. A., Ackerson, L. M., & Selby, J. V. (2000, April).
Self-monitoring of blood glucose: Language and financial barriers in a managed
care population with diabetes. Diabetes Care, 23(4), 477–483.
Kern, D. E., Branch, W. T., Jr., Jackson, J. L., Brady, D. W., Feldman, M. D., Levinson,
W., Lipkin, M., Jr., & General Internal Medicine Generalist Educational Leadership
Group. (2005, January). Teaching the psychosocial aspects of care in the clinical
setting: Practical recommendations. Academic Medicine, 80(1), 8–20. (Review)
Kleinman, A., Eisenberg, L., & Good, B. (1978) Culture, illness, and care: Clinical
lessons from anthropologic and cross-cultural research. Annals of Internal
Medicine, 88(2), 251–258.
Kirsch, I. S., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993). Executive summary of
adult literacy in America: A first look at the results of the National Adult Literacy
Survey, retrieved March 17, 2005, from
http://nces.ed.gov/naal/resources/execsumm.asp
L’Institut Roeher. (1999). Literacy, disability and communication: Making the
connection. Toronto, Ontario. See http://www.roeher.ca/english/about/about.htm
Lears, L. O., & Abbott, J. S. (2005, January/February). The most vulnerable among us.
Health Progress, 86(1), 22–25, 60.
Levin, S. J., Like, R. C., & Gottlieb, J. E. (2000). ETHNIC: A framework for culturally
competent clinical practice. In Appendix: Useful clinical interviewing mnemonics.
Patient Care, 34(9), 188–189.
Levinson, W. (1999, March/April). In context: physician-patient communication and
managed care. Journal of Medical Practice Management, 14(5), 226–230.
Page 68 of 73
Levinson, W., Roter, D. L., Mullooly, J. P., Dull, V. T., & Frankel, R. M. (1997,
February 19). Physician-patient communication. The relationship with malpractice
claims among primary care physicians and surgeons. Journal of American Medical
Association, 277(7), 553–559.
Levinson, W., & Chaumeton, N. (1999, February). Communication between surgeons
and patients in routine office visits. Surgery, 125(2), 127–134.
Liu, C. F., Hedrick, S. C., Chaney, E. F., Heagerty, P., Felker, B., Hasenberg, N., et al.
(2003, May). Cost-effectiveness of collaborative care for depression in a primary
care veteran population. Psychiatric Services, 54(5), 698–704.
Long, A., Scrimshaw, S. C. M., & Hernandez, N. (1992). Transcultural epilepsy services.
In N. S. Scrimshaw & G. R. Gleason (Eds.), Rapid assessment procedures:
qualitative methodologies for planning and evaluation of health related
programmes. Boston: International Nutrition Foundation for Developing Countries.
McArthur, L. H., Anguiano, R., & Gross, K. H. (2004, October). Are household factors
putting immigrant Hispanic children at risk of becoming overweight: A communitybased study in eastern North Carolina. Journal of Community Health, 29(5), 387–
404.
McKay, M. M., & Bannon, W. M. (2004). Engaging families in child mental health
services. Child and Adolescent Psychiatric Clinics of North America, 13(4), 905–
921.
Mutha, S., Allen, C., & Welch, M. (2002). Toward culturally competent care: A toolbox
for teaching communication strategies. San Francisco: Center for the Health
Professions, University of California, San Francisco.
Muzyk, A. J., Muzyk, T. L., & Barnett, C. W. (2004, May/June). Counseling Spanishspeaking patients: Atlanta pharmacists’ cultural sensitivity, use of languageassistance services, and attitudes. Journal of the American Pharmaceutical
Association, 44(3), 366–374.
Nance, T. A. (1995). Intercultural communication: Finding common ground. Journal of
Obstetrics and Gynecology, 24(3), 249–255.
Neuwirth, Z. E. (1999, September/October). An essential understanding of physicianpatient communication. Part II. Journal of Medical Practice and Management,
15(2), 68–72.
Newcomb, M. D., & Carmona, J. V. (2004, December). Adult trauma and HIV status
among Latinas: Effects upon psychological adjustment and substance use. AIDS
and Behavior, 8(4), 7–28.
Page 69 of 73
Ngo-Metzger, Q., Massagli, M. P., Clarridge, B. R., Manocchia, M., Davis, R. B.,
Iezzoni, L. I., & Phillips, R. S. (2003, January). Linguistic and cultural barriers to
care. Journal of General Internal Medicine, 18(1), 44–52.
Nutbeam, D. (2000). Health Literacy as a public health goal: A challenge for
contemporary health education and communication strategies into the 21st century.
Health Promotion International, 15(3), 259–267. Available from
http://heapro.oupjournals.org/cgi/content/abstract/15/3/259
Oquendo, M. A. (1996, June). Psychiatric evaluation and psychotherapy in the patient’s
second language. Psychiatric Services, 47(6), 614–618.
Owens, R. (2005). Language development: An instruction (6th ed). New York: Allyn
and Bacon.
Pullum, G. K. (1991). The great Eskimo vocabulary hoax and other irreverent essays on
the study of language (pp. 168–171). Chicago: University of Chicago Press.
Rhodes, K.V., Vieth, T., He, T., Miller, A., Howes, D.S., Bailey, O., Walter, J., Frankel,
R. & Levinson W. (2004). Resuscitating the physician-patient relationship:
emergency department communication in an academic medical center. Annals of
Emergency Medicine Sep;44(3):262-7.
Rhodes, R. L. (2000). Legal and professional issues in the use of interpreters: Guidelines
for school psychologists. NASP Communiqué, 29(1). See
http://www.nasponline.org/publications/cq291Interpreters.html
Rivadeneyra, R., Elderkin-Thompson, V., Silver, R. C., & Waitzkin H. (2000, April 15).
Patient centeredness in medical encounters requiring an interpreter. The American
Journal of Medicine, 108(6), 470–474.
Rosen, P. J., Hiller, M. L., Webster, J. M., Staton, M., & Leukefeld, C. (2004,
September). Treatment motivation and therapeutic engagement in prison-based
substance abuse treatment. Journal of Psychoactive Drugs, 36(3), 387–396.
Rosen, J., Spatz, E. S., Gaaserud, A. M., Abramovitch, H., Weinreb, B., Wenger, N. S., &
Margolis, C. Z. (2004, March). A new approach to developing cross-cultural
communication skills. Medical Teacher, 26(2), 126–132.
Ruether, S., St Claire, T., & Coffman, J. (2002). Making room for citizens at the public
policy table. Journal of Health and Human Services Administration, 24(4), 388–
400.
Schneider, J., Kaplan, S. H., Greenfield, S., Li, W., & Wilson, I. B. (2004, November).
Better physician-patient relationships are associated with higher reported adherence
to antiretroviral therapy in patients with HIV infection. Journal of General Internal
Medicine, 19(11), 1096–1103.
Page 70 of 73
Selener, D. (1991). Participatory evaluation: People’s knowledge as a source of power.
Networking Bulletin.
Smoot, S. L., & Gonzales, J. L. (1995, August). Cost-effective communication skills
training for state hospital employees. Psychiatric Services, 46(8), 819–822.
Stewart, M., Meredith, L., Brown, J. B., & Galajda, J. (2000, February). The influence of
older patient-physician communication on health and health-related outcomes.
Clinics in Geriatric Medicine, 16(1), 25–36, vii–viii.
U.S. Census Bureau. (2003). Census 2000 special tabulations 224 languages spoken at
home for the U.S. in 2000 or see
http://www.census.gov/population/www/cen2000/phc-t20.html
U.S. Census Bureau. (2004). Census 2000 special tabulations 224, languages spoken at
home (directly at
http://www.census.gov/mp/www/spectab/languagespokenSTP224.xls, but this is
very large and takes a long time to download. See also
http://www.census.gov/mp/www/spectab/)
U.S. Census Bureau. (2003). QT-P17. Ability to Speak English: 2000 Data Set: Census
2000 Summary File 3 (SF 3) - Sample Data Geographic Area: United States.
U.S. Department of Health and Human Services, Health Resources & Services
Administration, (n.d.). HP 2010: Health communication. Retrieved April 8, 2005,
from http://www.healthypeople.gov/Document/HTML/Volume1/11HealthCom.htm
U.S. Department of Health and Human Services. (2003). Communicating Health:
Priorities and Strategies for Progress. Washington, DC.
Westberg, S. M., & Sorensen, T. D. (2005, January/February). Pharmacy-related health
disparities experienced by non-English-speaking patients: Impact of pharmaceutical
care. Journal of the American Pharmaceutical Association, 45(1), 48–54.
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Acknowledgments
Process of Inquiry—Communicating in a Multicultural Environment of the Curricula
Enhancement Module Series was written collaboratively by M. Jean Gilbert, (California
State University, Long Beach); Yolanda Partida (Robert Wood Johnson Foundation);
Tawara Goode, Director; and Clare Dunne, Research Associate; (the National Center for
Cultural Competence (NCCC)) with the exception of Sections A and B which were
written by Tawara Goode and Clare Dunne.
The authors acknowledge with gratitude the valuable contributions of the following
persons:
 Christy Kavulic, Ed.D., CCC-SLP, curricula review of the final draft
 Wendy Jones, M.S.W., contributor of content on health literacy and individuals
with limited English proficiency
 M. Jean Gilbert, Ph.D., curricula review of the first draft
 Hortense DuVall, Editor
 John Richards, Mindy Nash, and Jon Quiros, Web layout and design (JR, please
update as needed)
 DRTE staff for their review and insightful input at every step of the process
Funding to support this project was provided by a grant from the Division of Research,
Training and Education (DRTE), Maternal and Child Health Bureau (MCHB), Health
Resources and Services Administration (HRSA), U.S. Department of Health and Human
Services (DHHS). The NCCC is funded and operates under the auspices of Cooperative
Agreement #U93-MC-00145-10 and is supported in part from the MCHB (Title V, Social
Security Act), HRSA, DHHS.
Permission is granted to reproduce this curricula enhancement module for noncommercial distribution. The requirement is that proper credit be given to the National
Center for Cultural Competence and authors.
Suggested Citation:
Gilbert, M.J., Partida, Y., Goode, T., & Dunne, C. (2005) Process of Inquiry—
Communicating in a Multicultural Environment. From the Curricula Enhancement
Module Series. Washington, DC: National Center for Cultural Competence, Georgetown
University Center for Child and Human Development.
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About the NCCC:
The mission of the National Center for Cultural Competence (NCCC) is to increase the
capacity of health care and mental health programs to design, implement, and evaluate
culturally and linguistically competent service delivery systems. The NCCC conducts an
array of activities to fulfill its mission including: (1) training, technical assistance, and
consultation; (2) networking, linkages, and information exchange; and (3) knowledge and
product development and dissemination. Major emphasis is placed on policy
development, assistance in conducting cultural competence organizational selfassessments, and strategic approaches to incorporating systematically culturally
competent values, policy, structures, and practices within organizations.
The NCCC is a component of the Georgetown University Center for Child and Human
Development (GUCCHD) and is housed within the Department of Pediatrics of the
Georgetown University Medical Center. It is funded and operates under the auspices of
Cooperative Agreement #U93-MC-00145-10 and is supported in part from the Maternal
and Child Health program (Title V, Social Security Act), Health Resources and Services
Administration, Department of Health and Human Services (DHHS). Since its inception,
the NCCC has shared partnerships with two federal departments, two federal
administrations, one federal agency, and nine of their respective bureaus, divisions,
branches, offices, foundations, and programs. The NCCC conducts a collaborative project
under the auspices of another Cooperative Agreement with the GUCCHD and the Center
for Mental Health Services, Substance Abuse and Mental Health Services
Administration, DHHS. The NCCC also has partnerships with foundations, universities,
and other non-governmental organizations (NGOs).
The National Center for Cultural Competence
3300 Whitehaven Street, NW, Suite 3000
Washington, DC 20007-2401
PHONE: (202) 687-5387 or (800) 788-2066
TTY: (202) 687-5503
FAX: (202) 687-8899
E-MAIL: cultural@georgetown.edu
INTERNET: http://gucchd.georgetown.edu/nccc
Notice of Non-Discrimination
In accordance with the requirements of Title VI of the Civil Rights Act of 1964, Title IX
of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973,
and implementing regulations promulgated under each of these federal statutes,
Georgetown University does not discriminate in its programs, activities, or employment
practices on the basis of race, color, national origin, sex, age, or disability. The statutes
and regulations are supervised by Rosemary Kilkenny, Special Assistant to the president
for Affirmative Action Programs. Her office is located in Room G-10, Darnall Hall, and
her telephone number is (202) 687-4798.
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