Brokering Language and Culture: Can Ad Hoc Interpreters Fill the Language Service Gap at Community Health Centers?

Abstract

The purpose of the research was to explore the ability of ad hoc interpreters to integrate into the organizational climate at a federally qualified community health clinic (CHC) and create satisfactory services for limited–English-proficiency clients. Survey and interview data were gathered from staff (n = 17) and Latino clients (n = 30). The data indicate that clients felt satisfied with interpreters. Some friction existed between the interpreters and the medical staff due to incongruent expectations. The CHC's organizational climate and the interpreters' commitment to the Latino community mediated the impact of these tensions on services and satisfaction. The study offers important insight into how ad hoc interpreters can become professional medical interpreters within a limited-resource service environment.

KEYWORDS:

• Interpreters
• limited–English-proficient clients
• Latinos
• organizational climate
• community health clinics
• health access

Introduction

Federally qualified community health centers' (CHCs) long-standing relationship with providing healthcare services for individuals with limited access to insurance has made them leaders in providing healthcare for immigrant populations (ARCNFCO, 2005; Casey, Blewett, & Call, 2004). The need for accessible high-quality interpretation services at CHCs has become increasingly important due to the recent rapid rise of immigrant populations across the United States, a significant number of whom have limited English proficiency (LEP) (Elderkin-Thompson, Silver, & Waitzkin, 2001; Kouyoumdjian, Zamboanga, & Hansen, 2003; Karliner, Perez-Stable, & Gildengorin, 2004; Ku & Flores, 2005; The California Endowment, 2004). Beyond factors created by client needs, CHCs are directed by federal law and concerns about accurate communication between healthcare staff and clients to improve access to quality interpretation services for LEP clients (ARCNFCO, 2005; Youdelman & Perkins, 2005).

There is a general consensus among healthcare professionals and scholars that of the current interpretation service models, which include professional medical interpreters, telephone interpreters (for example, AT&T Language Line), ad hoc interpreters, family members, and no interpreter, professional medical interpreters offer the most effective model to address the well-documented language and cultural barriers faced by LEP clients (Hatton & Webb, 1993; Hornberger, Itakura, & Wilson, 1997; Reiff, Zakut, & Weingarten, 1999; The California Endowment, 2004; ARCNFCO, 2005). Despite the significant forces created by client needs, federal law, and general consensus among healthcare professionals, there are still limited opportunities, particularly in rural areas, for CHCs to hire professionally trained medical interpreters (Casey et al., 2004). As a result of this workforce gap, CHCs with low access to professionally trained medical interpreters and limited resources may at times employ ad hoc interpreters, individuals with bilingual skills but no formalized training in medical interpretation (Casey et al., 2004). Understanding the factors that assist ad hoc interpreters in developing the skills and behaviors associated with professional medical interpreters might provide insight into the how CHCs can build high-quality medical interpretation services for LEP clients despite the lack of access to trained professional medical interpreters.

MEDICAL INTERPRETATION SERVICES

The concern among healthcare providers that clients who experience language barriers during treatment do not receive the best possible care because of miscommunication is a significant factor in the need for high-quality medical interpretation services. A recent survey by the Institute of Medicine found that 51% of medical staff believed patients do not adhere to treatment because of culture or language barriers and that 56% of these same medical staff reported having no language or cultural competency training (Youdelman & Perkins, 2005). This finding as well as others (Abbe, Simon, Angiolillo, Ruccione, & Kodish, 2006; Hudelson, 2005; Casey et al., 2004) highlight that many providers are challenged by a shortage of knowledge and resources to address the well-documented needs of LEP clients.

In addition to concerns about the quality of care for LEP clients, interest in medical interpretation services may also be linked to Title VI of the Civil Rights Act of 1964, which requires “healthcare facilities that receive federal funding through Medicaid, [the State Children's Health Insurance Program], Medicare, or any other source to take reasonable steps to provide people with limited English proficiency with meaningful access to their services” (ARCNFCO, 2005, p. 28). These standards are reinforced by the U.S. Department of Health and Human Services (DHHS) 45 C.F.R. Section 80.3(b)(2), which states “Recipients [agencies] may not utilize criteria or methods of administration which have the effect of subjecting individuals to discrimination because of their race, color, or national origin …” Title VI and the standards from DHHS put into place a set of rules that establish a significant legal motivation for healthcare agencies to provide medical interpreter services for LEP clients (Snowden, Masland, & Guerrero, 2007).

Karliner, Jacobs, Chen, and Mutha (2007) suggest that there are four general areas in the research literature concerning medical interpretation services: communication (comprehension and errors), utilization of clinical services, clinical outcomes, and satisfaction with clinical care. In their meta-analysis of articles concerning medical interpreters contained in PubMed and PsycINFO between 1966 and 2005, findings consistently favored professional medical interpreters over ad hoc interpreters across the four areas. A similar meta-analysis conducted by Flores (2005) found that the best healthcare services for LEP clients were provided by professional medical interpreters or language-concordant medical staff. In general, findings indicated that the use of professional interpreters resulted in care that compared favorably with that provided to non-LEP clients (Flores, 2005; Karliner et al., 2007).

Similarly, when professional medical interpreters were compared to language-concordant medical staff, findings indicated that professional medical interpreters were capable of providing communication that approximated the same level of accuracy as the language-concordant staff (Green et al., 2005). A more nuanced examination of the data indicated that LEP clients asked fewer questions concerning mental health and other highly sensitive issues even when professional medical interpreters were employed. However, beyond this, the accuracy, satisfaction, and outcome of services were not significantly different. The consistency of findings in the scholarly literature speaks to the value of professional medical interpreters and their ability to reduce medical misunderstandings and increase patient satisfaction for LEP clients (Reiff et al., 1999; Norris et al., 2005).

Unfortunately, there are few formalized opportunities for individuals interested in training as a professional medical interpreter (ARCNFCO, 2005). The assortment of unrelated certificate programs offered from a variety of sources and the lack of a clear career path have left a serious gap in the workforce (Roat, 2006). Often, medical settings with financial resources rely on private companies providing interpretation services manned by individuals trained primarily in business and diplomatic interpretation, which have a slightly more advanced system of training and professional development than medical interpretation (Roat, 2006). The strong focus on the enforcement aspects of the federal civil rights law as a tool to address the language service gap has done little to fix the workforce gap. Further, there does not appear to be any serious movement from the federal or state governments or private health insurance companies to address the insufficient funding for interpretation services. All of these issues are substantial barriers for CHCs that need to provide access to high-quality interpretation services for LEP clients.

Ad Hoc Interpreters

Ad hoc interpreters may offer an opportunity to create an agency-level approach to addressing the workforce gap in professional medical interpreters. Despite research that has consistently reported ad hoc interpreters create lower levels of satisfaction and higher levels of communication errors than professional interpreters, they have the most important prerequisites to becoming professional medical interpreters: bilingual fluency and a desire to interpret. Several factors such as interpreter training, medical staff training to work with interpreters, and style of interpretation have been shown to influence the effectiveness of the interpretation services, thereby clarifying best practices for professional medical interpreters (Hatton & Webb, 1993; Karliner et al., 2004; Flores, 2005). Less understood is how ad hoc interpreters, individuals who present with bilingual/multilingual language skills but little or no training associated with the provision of medical services, develop the skills identified as best practices in the scholarly literature and become professional medical interpreters. Understanding how CHCs can create a cost-effective method to help ad hoc interpreters move to the skill level of professional medical interpreters offers an important alternative to waiting for increases in the numbers of professional medical interpreters or language-concordant medical staff.

CHCs interested in employing ad hoc interpreters will have to train and acculturate individuals with bilingual/multilingual skills into the medical culture as well as provide ongoing training specific to medical interpretation, often with limited access to formalized training programs or financial resources. There are many facets to this process, including the agency-level factors that encourage professional growth, the identification of specific interpretation skills that need to be developed, and the training process for teaching those skills. Of these factors, little is currently known about the agency-level factors that may shape the development of ad hoc interpreters. The focus of this research is the agency-level factor of organizational climate because it is likely to play an important role in shaping the ad hoc interpreters' training; introduction to medical culture; interactions with other staff; and the style, quality, and outcomes of their interpretations (Hatton & Webb, 1993; Karliner et al., 2004; Flores, 2005).

ORGANIZATIONAL CLIMATE

Organizational climate includes aspects of shared history, expectations, unwritten rules, and social mores that affect the behavior of everyone in an organization and the underlying beliefs that shape the actions of staff (Frederickson, 1966; Glisson, 2000). It is theorized to influence access and utilization of healthcare services because of its role in shaping staff behavior toward clients (Muldrow, Buckley, & Schay, 2002; Glisson, Dukes, & Green, 2005).

The triadic relationship between the healthcare provider, interpreter, and LEP client is complex. The agency setting provides the context for these three actors to interact, playing a vital role in shaping and constraining their relationships. In doing so, the organizational climate is likely to influence the development of ad hoc interpreters' skills and perceptions by defining their role in medical services, the value of their services, and in some ways the distribution of goods associated with those services.

CHCs that successfully navigate the introduction and use of ad hoc interpreters seem likely to have an organizational climate that fosters opportunities for professional growth and assists ad hoc interpreters' integration into medical culture. The limited literature about medical interpreters also suggests that training, perceived role, and length of employment may influence their relationships with the organizations they work for and the clients they serve (Flores, 2005; Karliner et al., 2007).

COMMUNITY HEALTH CENTERS

CHCs began as a demonstration project in 1965 and were intended to provide comprehensive primary care for low-income, medically underserved communities (Markus, Roby, & Rosenbaum, 2002). Today, CHCs provide comprehensive primary care, pediatrics, internal medicine, obstetrics, lab work, and in some cases, mental health services. These services are provided regardless of ability to pay, insurance status, or residency status (Markus et al., 2002). Since 2000, federal spending on CHCs has nearly doubled. The results are 200 new CHCs across the United States and a 53% increase in clients served. During this period of growth, the number of Latino clients accessing services increased by 52% (Wheeler, 2007).

There are two significant reasons for choosing a CHC as the setting in which to study ad hoc interpreters in healthcare. First, recently arrived Latinos have growing rates of service utilization from CHCs across the United States for a variety of reasons related to their insurance status and the role of CHCs in the healthcare system, thereby offering a fertile environment to study services related to LEP clients (Kouyoumdjian et al., 2003). Second, because CHCs serve racially and culturally diverse populations, they tend to “develop valuable expertise in providing care that is culturally responsive and linguistically accessible” (The California Endowment, 2004, p. 2). This service environment could therefore provide insight into the innovative use and development of ad hoc interpreters to address the needs of LEP clients.

RESEARCH QUESTIONS

Three questions framed the research. First, were the ad hoc interpreters able to integrate into the CHCs' organizational climate? Second, how satisfied with the medical services were clients who needed and used the ad hoc interpreters? Third, did the ad hoc interpreters make progress toward demonstrating behavior similar to professional medical interpreters?

METHODS

This is a case study of one CHC. A general induction method was used to interpret the data, in that there were some tentative thoughts about the functioning of the ad hoc interpreters based on the literature, but no strong preconceived notions regarding their ability to progress toward professionalism or the role that organizational climate might play in that progress (Thomas, 2006). Quantitative and qualitative data were collected from ad hoc interpreters staff and clients at the CHC. The quantitative instruments were used to investigate the research questions, which were developed from a review of the literature concerning organizational climate and medical interpreters. The qualitative methods built on the findings from the initial quantitative methods, intentionally seeking to expand on the data from the quantitative instruments.

Mixed methods were used in response to the limited ability within this one case to statistically link the concepts of organizational climate, skill development, and client satisfaction from the perspectives of clients, staff, and ad hoc interpreters in any meaningful way given the number of participants and cross-sectional approach. Mixed methods offered an alternative approach that allowed for measuring multiple perspectives concern the ad hoc interpreters and then to examine the congruency between these perceptions. The mixed methods therefore served two specific purposes: First, they helped clarify the role of the medical interpreters in the CHC and the relationship that role had with creating treatment outcomes. The intent was to elaborate and enhance the multiple views of the interpreters held by clients, staff, and the interpreters themselves (Greene, 2001). Second, the mixing of data collection modes offered an opportunity to discover new perspectives about the ad hoc interpreters' growth toward providing professional medical interpretation services by using a different set of methodologies to recast the findings from the quantitative data collection instruments (Caracelli & Greene, 1997; Greene, 2001).

Location

The CHC is located in the Midwest in a Core-Based Statistical Area, a Census Bureau designation used to identify an area that contains a Metropolitan Statistical Area (MSA) with one or more adjacent rural areas that are integrated by close proximity and commuting. The MSA in which the CHC is located has an estimated population of 175,000. The large rural area surrounding the MSA is part of a depressed agricultural and manufacturing region. In the MSA, the population is 78% White, 11.5% African American, 0.2% Native American, 6.5% Asian American, and 3.8% Latino. Almost all of the population in the surrounding rural areas is White (U.S. Census Bureau, 2005).

Between the 1990 census and the 2005 census supplement, the Latino population grew from 2% to 3.8%, nearly doubling in size. The growth of individuals older than 5 who did not speak English at home during the same time period was more than 4% (9% of the population fit this category in 1990 and 13.2% in 2005; U.S. Census Bureau, 2005). In 2003, the CHC served approximately 450 individuals who self-identified as Latino.

Ad Hoc Interpreters

The CHC added ad hoc interpreters approximately 6 years prior to data collection in response to the growing Latino population. All of the ad hoc interpreters were hired in the dual roles of medical file clerks and interpreters. All were initially observed in the waiting room interpreting for family and/or friends seeking services at the CHC. After this initial observation, the ad hoc interpreters were approach about potential employment.

Other than an assessment from an outside consultant on the fluency that contained some basic tips on medical interpretation, the ad hoc interpreters were not formally trained. The medical staff also had no formalized training in working with medical interpreters. The ad hoc interpreters' primary funding stream was from the medical file clerk position. Expectations that both jobs would be fulfilled in a timely and professional fashion were strong.

Research Participants

Data were collected from staff, clients, ad hoc interpreters, and to better understand how the ad hoc interpreters integrated into the CHC from the perspectives of multiple key stakeholders. Staff provided a perspective on the ad hoc interpreters' movement toward professional service provision and integration into the organizational climate. Clients' data on satisfaction provided a measure of the interpreters' ability to meet the healthcare expectations of patients and offered an alternative perspective on the ad hoc interpreters' ability to provide professional medical services.

Staff

The inclusion criteria for staff were employment of at least quarter time at the CHC and regular contact with Latino clients. Otherwise, staff participants were self-selecting. The total population of staff who met the inclusion criteria was 28 of whom 17 participated. The mean reported age of the participating staff was 46 years, the majority were female, and the average tenure at the agency was approximately 3 years. A full range of staff including administrators, direct service providers, and support staff completed the staff measurement instruments.

Ad Hoc Interpreters

The CHC employed three interpreters at the time of data collection. The average number of years working for the agency was approximately 5, all interpreters presented as bilingual and bicultural, and most were from countries of origin outside of the United States. Between the completion of quantitative data collection and the focus group, one of the Latina ad hoc interpreters left and was replaced by a White ad hoc interpreter who at the time of the focus group had been at the CHC for less than 12 months.

Clients

Possible client candidates were invited to participate in the research by fliers and staff word of mouth. Inclusion criteria for client participants consisted of 5 years or less of residency in the United States (recently arrived), country of origin in South or Central America or Mexico, and adults (aged 18 to 65) who had received or had an immediate family member who had received medical services at the CHCs and agreed to participate in the study. Most participants were from Mexico and all had direct contact with medical staff and the ad hoc interpreters.

The sample size was 30 clients, or approximately 6.7% of the annual Latino population served by the CHC in 2003 (N = 450). The average age of participants was 32 years (SD = 10), 63% were female (n = 19), 30% (n = 9) had less than an 8th grade education, 23% (n = 7) had some high school, 33% (n = 10) completed a high school diploma or GED, 7% (n = 2) completed some college, and 7% (n = 2) completed a college degree.

Staff Measurement Instruments

Organizational climate

Staff members' perceptions of the organizational climate were measured with the Work Environment Scale-Real (WES), a 91-item paper-and-pencil measurement instrument with true/false response options. The WES specifically measures the social environment in work settings by evaluating individuals' self-reported perceptions of their workplace. It can be used to formulate case descriptions and to understand the impact of organizational climate on staff and clients (Moos, 1994).

The WES was normed on 4,879 healthcare workers from outpatient medical settings, psychiatric clinics, community mental health centers, children's residential treatment centers, state mental hospitals, general hospital units, and Department of Veterans Affairs medical centers (Moos, 1994). It has three broad dimensions: system maintenance (level of organization at the work setting), goal orientation (level of job challenge), and relationships (type of social interactions among workers and supervisors). Within the three dimensions there are 10 subscales with adequate internal consistency (Cronbach's alpha scores between .69 and .83) and good predictive validity in healthcare settings (Moos, 1994). The 10 subscales have a range of scores between zero and nine. For involvement, cohesion, support, autonomy, task orientation, clarity, innovation, and comfort, higher scores indicate better work conditions. The work pressure and control subscales are interpreted inversely, with lower scores indicating better work conditions.

The WES subscales are described by Moos (1994, p. 1) as follows: “(1) Involvement is the extent to which employees are concerned about and committed to their jobs. (2) Cohesion is how much employees are friendly and supportive of one another. (3) Support is the extent to which management is supportive of employees and encourages employees to be supportive of one another. (4) Autonomy is how much employees are encouraged to be self-sufficient and to make their own decisions. (5) Task orientation is the emphasis on good planning, efficiency, and getting the job done. (6) Work pressure is the degree to which high work demands and time pressure dominate the job milieu. (7) Clarity is whether employees know what to expect in their daily routine and how explicitly rules and policies are communicated. (8) Managerial control is how much management uses rules and procedures to keep employees under control. (9) Innovation is the emphasis on variety, change, and new approaches. (10) Physical comfort is the extent to which the physical surroundings contribute to a pleasant work environment.”

AD HOC Interpreter focus group

Six open-ended questions were used to clarify the ad hoc interpreters' perceptions of the agency. The questions were (1) Did you understand the instructions and questions associated with the WES? (2) Please define your role as an interpreter. (3) Have you received any training specific to your tasks as an interpreter? If yes, please describe the training. (4) How long have you worked at this particular CHC? (5) In general, how long do you see yourself providing translation services in a medical setting? (6) What advice do you have for CHCs looking to employ interpreters for recently arrived Latinos?

Question one insured that the data provided from the WES accurately reflected the perceptions of the ad hoc interpreters. Questions two through six were intended to focus on the ad hoc interpreters' experiences, expanding on the information obtained from the WES.

Client Measurement Instruments

Satisfaction with services

The Client Satisfaction Scale (CSQ-8) was used to measure clients' level of satisfaction with the CHC's services. The CSQ-8 is normed on a wide range of clients receiving social and health services of various forms in the United States. It has excellent reliability, as supported by Cronbach's alpha scores between .86 and .94 (Attkisson & Zwick, 1982). Fischer and Corcoran (1994) report that the instrument has good validity but did not elaborate on the specific method used to determine this or report any results. It is an 8-question, standardized paper-and-pencil measurement instrument that uses a 4-point Likert scale. The range of possible scores is between 8 and 32. A score of 24 or more indicates that the respondent has been mostly to highly satisfied with the services they received (Nguyen, Attkisson, & Stegner, 1983).

Perceptions of interpreters

Clients' perceptions of the ad hoc interpreters and services were examined using 5 questions with structured answers and a catchall category. The questions were (1) How did you hear about the CHC? (2) What do you like most about the interpreters at the CHC? (3) What makes you comfortable? (4) What makes you uncomfortable? (5) How has coming to CHC impacted your life? The questions provided opportunities for clients to reflect and expand on the services associated with the ad hoc interpreters.

Data Collection

Staff participants received hard copies of measurement instruments (along with a cover letter explaining the project and outlining voluntary participation) from the agency director. Staff were asked to complete the instruments at their convenience and place them in a secure survey box at the agency. The data were collected anonymously and consent was passive.

For the focus group, no recording devices were used and only written notes were taken (Emerson, Fretz, & Shaw, 1995). Consent was passive, ensuring that there was no written record of participation. The focus group took place in a room provided by the CHC in December 2005. It lasted approximately 1 hour and was conducted by two members of the research team, one of whom is bilingual/bicultural.

Client participants completed the two instruments (CSQ-8 and Perceptions of Interpreters) on a laptop computer with assistance from a bicultural/bilingual member of the research team. The electronic versions of the data collection instruments were in Spanish and English and designed to move data from the instruments to a database without the process of data entry by a third party. The data were collected anonymously and consent was obtained orally. All participants completed the instruments in Spanish.

Data Analysis Plan

Staff

The data from the WES were used to develop a case profile of the CHC included in the study (Moos, 1994). This profile was then compared to the average interpreters' score and the group of 4,879 healthcare workers used to norm the WES using line graphs (Moos, 1994).

The narrative data gathered from the interpreter focus group were examined by the principal investigator and a co–principal investigator. Notes from the focus group were reviewed to identify emerging themes. Next, the co–principal investigators compared notes to identify common and divergent themes. These themes were then reexamined by the two researchers within the context of current knowledge about the agency's function, which was based on the intense observation created by data collection. A third researcher checked the authenticity of identified themes (Guba & Lincoln, 1989).

Clients

Frequency distributions and crosstabs were used to examine clients' responses to the Perceptions of Interpreters and the CSQ-8. The demographic factors of age, sex, and level of education were also examined for possible effects on CSQ-8 scores using crosstabs.

FINDINGS

Were the Ad Hoc Interpreters Able to Integrate Into the CHC's Organizational Climate?

The WES profile of the CHC indicated that there were some strengths within the agency. In particular, the staff reported moderately higher than usual levels of cohesion (M = 5.8), support (M = 5.5), autonomy (M = 6.1), and innovation (M = 4.7) and lower than usual levels of work pressure (M = 4.2) and control (M = 4.2). The subscale scores were 10% to 26% (0.6 to 1.5 points) better than those reported by the healthcare population used to norm the WES, indicating in these areas of organizational functioning that the CHC had a more positive work environment than might be expected (Figure 1). The involvement and task orientation subscales were less than 10% (0.3 points) higher than the norms. The lowest score overall was the Physical Comfort subscale, which was 53% (2 points) less than the scale norm.

When the ad hoc interpreters (n = 3) were separated from the other CHC staff, there were substantial differences across the subscales. The ad hoc interpreters registered 60% (2.8 points) higher levels of work pressure than the other staff, 23% (1.3 points) higher than the norm. In other subscales, the ad hoc interpreters expressed 41% (2.1 points) less involvement with the organization than other staff, 74% (2.9 points) less clarity about the rules and policies directing daily behavior, 51% (3.1 points) lower task orientation, and 79% (3.7 points) fewer opportunities for innovation than other staff (see Figure 1).

FIGURE 1 WES profiles.

The focus group with ad hoc interpreters expanded the findings contained in the WES, with the experienced ad hoc interpreters being more confirmatory of the findings from the WES. The more tenured ad hoc interpreters had been at the agency for an average of 4.5 years, while the newer ad hoc interpreter had been at the agency for less than 1 year. The ad hoc interpreters with more tenure describe an evolution of their relations with staff. One of them captured this evolution when describing her work space: “First we had no place, then we had a closet, now in the new building we participated in designing our own office space.” The more tenured ad hoc interpreters' perceptions were influenced by an aggregate experience of organizational climate, which contained the struggles associated with starting a new service within a financially constrained CHC. The newer ad hoc interpreter entered the organization at a time and climate that had benefited from this positive evolution.

The ad hoc interpreters also described high levels of client involvement in the workplace and fairly intense relationships with the wider Latino community. This involvement was a source of job satisfaction. Given the intimate nature of providing medical translation, the ad hoc interpreters were privy to highly confidential information about clients. One ad hoc interpreter stated: “I feel like I am part of clients' lives and families.” This high level of involvement was a strength that helped solidify the high expectations for high-quality service provision by the ad hoc interpreters.

Contained in Table 1 are additional subthemes associated with the accuracy of the WES, the relationships ad hoc interpreters had with other staff, and the ad hoc interpreters' commitment to the Latino community.

How Satisfied With the Medical Services Were Clients Who Needed and Used the Interpretation Services?

The average CSQ-8 score was 30.23 (SD = 2.97), with a minimum score of 22 and a maximum of 32. Ten percent (n = 3) of the sample scored something less than “satisfied with services.” There was no significant difference in CSQ-8 scores between men and women or among the various educational levels represented in the sample. All of the clients who were less than satisfied with services were between the ages of 26 and 29. Please see Table 2 for complete information.

Clients' perceptions of the ad hoc interpreters and the services at the CHC show that 100% reported improved health and family life as a result of the assistance received from the CHC. None stated that their problems either remained the same or worsened. Clients shared comments at the end of the interviews that pointed to a sense of security associated with having access to healthcare and improved participation in family life because of better health. When asked specifically about the ad hoc interpreters, 17% (n = 5) stated that the fact that the ad hoc interpreters spoke their language was most important, 3% (n = 1) stated that the ad hoc interpreters' knowledge of U.S. culture was most important, and 80% (n = 24) thought the ad hoc interpreters' ability to communicate the clients' needs was most important. What was most important did not appear related to who was less than satisfied with services (see Table 3).

TABLE 1 Themes From Interpreter Focus Group

Themes
There were no problems with understanding and completing the WES.
Interpreters with more experience expressed stress about managing clerical duties and staff expectations to provide timely translation services.
Dual job roles create opportunities for closeness with clients. Client closeness was identified as a source of job satisfaction.
All had strong ties to the Latino community in the form of spouses, friends, family, and other employment.
Interpreters reported having no formal medical translation training, and language skills varied from native speakers to second language.
Interpreters expressed a long-term interest in healthcare and language.
Interpreters were asked to translate verbatim but sometimes felt they needed to adjust to convey appropriate meaning.
The medical staff expect verbatim translation.
The CHC had no formal recruitment methods to employ translators.
Timely translations are impeded due to overcommitment and staff shortages. The inability to provide timely translation creates friction with medical staff.
There is little opportunity for innovation to change other staff behavior.
There is much opportunity to be innovative on a personal level, e.g., when interacting with clients.
There was some level of desire for additional training, but interpreters were unsure of what training would contain.

TABLE 2 Crosstabs Educational, Sex, and Age Distributions and CSQ-8 Scores

	Less than satisfied with services (CSQ-8 score ≥24)	Satisfied with services (CSQ-8 score <24)
Level of education
8th grade or less		33% (n = 9)
Some high school	33% (n = 1)	22% (n = 6)
High school graduate/GED	33% (n = 1)	33% (n = 9)
Some university	33% (n = 1)	4% (n = 1)
University graduate		4% (n = 1)
Total (N = 30)	n = 3	n = 27
Sex
Female	65% (n = 2)	63% (n = 17)
Male	35% (n = 1)	37% (n = 10)
Total (N = 30)	n = 3	n = 27
Age
18–21		11% (n = 3)
22–25		19% (n = 5)
26–29	100% (n = 3)	15% (n = 4)
30–33		19% (n = 5)
34–37		19% (n = 5)
Older than 38		30% (n = 8)
Total (N = 30)	n = 3	n = 27

TABLE 3 Crosstabs Perceptions of Interpreters and CSQ-8 Scores

	Less than satisfied with services (CSQ-8 score ≥24)	Satisfied with services (CSQ-8 score <24)
Most important attribute of ad hoc interpreters
Spoke same language	35% (n = 1)	15% (n = 4)
Knowledge of U.S. culture		4% (n = 1)
Ability to communicate clients' needs	65% (n = 2)	81% (n = 22)
Total (N = 30)	n = 3	n = 27
How clients found out about the CHC's services
Family members	100% (n = 3)	44% (n = 12)
Friends		37% (n = 10)
Refugee center or Latino periodical		19% (n = 5)
Total (N = 30)	n = 3	n = 27

Clients were most likely to hear about the CHC from other family members who used it (n = 15). The next largest group was clients who heard about the CHC from friends (n = 10). The remaining clients heard about the CHC either from a Spanish-language periodical or the Center for Refugees. All of the clients who were less than satisfied with services were referred by family members (see Table 3).

Did the Ad Hoc Interpreters Make Progress Toward Demonstrating Behavior Similar to Professional Medical Interpreters?

The WES profile describes an agency with a number of strengths that would appear to make it amenable to integrating ad hoc interpreters and helping them move to the level of professional medical interpreters. The data further indicate that the ad hoc interpreters were able to fulfill the varying expectations held by clients and staff creating high levels of service satisfaction. The ad hoc interpreters also appear to often meet the expectations around language services created by referral sources, which in this case were likely to place a premium on the ability of the ad hoc interpreters to help clients overcome culture and language barriers to healthcare services. These outcomes demonstrate some level of professionalism.

The data indicate that the organizational climate of the CHC did shape how the ad hoc interpreters viewed themselves and functioned. The negative aspects of this relationship signified that integration into the larger organizational climate needs further work before the ad hoc interpreters share the same view of the agency as the other medical staff. The focus group further revealed more specific friction between the ad hoc interpreters and the medical staff due to incongruent expectations created during intense moments and related to needs associated with fulfilling multiple roles.

The experienced ad hoc interpreters in this study showed the most congruency with the high stress levels that were seen in the WES scores. For instance, when asked to talk about the stress level, those who had been at the agency longer expressed frustration with multitasking with medical records and interpreting. In contrast, the newer ad hoc interpreter was more likely to see the two roles as complementary. These changes in the CHC and its organizational climate may explain some of the discrepancies in the WES scores reported by the ad hoc interpreters and clients' perceptions of services provided by the ad hoc interpreters.

Limitations

First, the method should be considered exploratory and the findings preliminary. The case study method limits the results to the CHCs and the geographic area in which the research was conducted and may not be valid in other areas with different demographic characteristics. In particular, the case is most relevant for CHCs that have experienced growth in LEP clients, have limited access to professional medical interpreters, and have some contact with bilingual individuals interested in acquiring the skills associated with being a professional medical interpreter. Second, the mixing of methods allowed for examining multiple perspectives but did not allow for an analysis that directly connected these perspectives. Third, because of the cross-sectional nature of the research, there was no attempt to measure progress in specific interpretation skills over time as an indicator of professional development. Rather, clients' level of satisfaction with services and self-reported changes in health were used as indicators of movement toward professional-level medical interpretation. Although not as rigorous an approach as a pre- and post-test measure of specific skills, the method was appropriate given the exploratory nature of the research. Further, client satisfaction and self-reported level of health have been used by a number of other researchers to study the effectiveness of medical interpretation services (Flores, 2005; Karliner et al., 2007). Finally, caution must always be taken when considering the value and accuracy of field notes. Standard procedure when engaging individuals or groups about sensitive topics (such as discussing the professional relationships within a small agency or speaking with immigrants seeking healthcare) is to create a level of comfort that allows for honest discourse. Recording devices may interfere with this process; therefore, relying on the oldest tradition of recording observations in research, namely field notes, is preferable (Emerson et al., 1995). The validity of the field notes is strengthened by the triangulation afforded by the WES and the CSQ-8.

DISCUSSION

The mandating of language-appropriate services for LED clients under Title VI of the Civil Rights Act of 1964 is an important but limited approach to fixing the gap in language services at CHCs. One of the fundamental problems with Title VI's mandate is the lack of a trained interpreter workforce or even a formalized method for building that workforce (Segal, 2007; Casey et al., 2004). Developing ad hoc interpreters at the agency level could offer a viable solution to this workforce gap. Westermeyer (1990) suggests that after ad hoc interpreters have been identified that they learn by watching an experienced interpreter on the job, followed by supervised work and supplemented by formal classroom experiences. The creation of National Standards for Culturally and Linguistically Appropriate Services by the U.S. DHHS Office of Minority Health in 2000 offers a set of professional standards for the content of training programs. The newly formed Society of Medical Interpreters offers a professional organization for individuals interested in further solidifying the professional status of medical interpreters (ARCNFCO, 2005). The existence of training models, professional standards, and a professional organization provide some of the structural supports necessary for CHCs interested in developing ad hoc interpreters into professional medical interpreters.

As Snowden et al. (2007) point out, Title VI may not officially be an unfunded mandate under the Unfunded Mandates Reform Act of 1995, but it has almost no financial resources associated with it. The CHC in this research creatively used resources within the agency to employ and train ad hoc interpreters in response to a growing need within the local community. In particular, funding for the CHC's medical clerk positions was used to create paid employment for the ad hoc interpreters that was not contingent on reimbursement for interpretation services. Because the duties of the medical clerk jobs did not disappear, the interpreters were required to perform the tasks associated with both positions. One of the downsides to this approach was that the ad hoc interpreters reported fairly high levels of work pressure. Recognizing this problem, the CHC recently decided to train the ad hoc interpreters as nurse assistants, creating a funding stream more closely related to the medical services they interpret for. Changes in federal funding policy under Medicaid/Medicare and private health insurance reimbursement rules that formalized a sufficient funding stream for interpretation services would provide significant support to CHCs interested in developing ad hoc interpreters into professional medical interpreters (Youdelman & Perkins, 2005). For example, a sufficient funding stream associated directly with interpretation services most likely would have decreased the work pressure experienced by the ad hoc interpreters in this case study and allowed the CHC to focus their limited training resources on the job aspects related to medical interpretation.

Making training programs available represents another significant barrier to the use of ad hoc interpreters as a solution to the language service gap (ARCNFCO, 2005; Casey et al., 2004). The ad hoc interpreters who participated in this research expressed a long-term desire to continue providing interpretation services, but uncertainty about educational opportunities. The community college system could offer an access point to training programs for ad hoc interpreters working in CHCs located in rural areas (ARCNFCO, 2005; Casey et al., 2004). Waukesha Community Technical College in Wisconsin, for example, developed a curriculum leading to a technical diploma in issues related to interpreting in health fields (www.wctc.edu). The curriculum provides interpreters in training with linguistic and cultural proficiency that acknowledges the professional uniqueness of medical interpreting. It also provides opportunities for interpreters and medical staff to expand their knowledge and conception of medical interpreters' role in healthcare services. Through training programs coordinated between CHCs and community colleges, ad hoc interpreters could have a standardized path to professional status.

CONCLUSIONS

The exploratory research presented here indicates that in the current funding and policy environment, an agency-level solution structured around the development of ad hoc interpreters may be an effective method to close the language service gap at CHCs (Casey et al., 2004). Although the incorporation of ad hoc interpreters at the studied CHC encountered a number of challenges, attention to their unique work situation mitigated high turnover, low levels of commitment to clients, and a decline in overall satisfaction with services by LEP clients. In particular, the CHC's organizational climate, with higher than usual levels of support and innovation, coupled with the interpreters' commitment to the Latino community played a substantial role in helping the ad hoc interpreters develop and evolve over the years toward becoming professional medical interpreters. The case study indicates that this process could have been strengthened by the availability of funding that made full-time medical interpreting a viable healthcare profession and formalized training that provided a pathway to professional status.