Technical Meets Traditional: Language, Culture, and the Challenges Faced by Hmong Medical Interpreters

Initial Psychometric Testing of a Pain Quality Pictogram Tool Among Hmong Limited English Proficient and Bilingual Community Members and Healthcare Practitioners

PURPOSE

To assess the matching and content validity of a pain quality pictogram tool with a Hmong community.

DESIGN

A Qualtrics survey was administered to two groups of participants.

METHODS

Sixty Hmong participants (n = 49 limited English proficiency and bilingual Hmong community members in group 1; n = 11 bilingual Hmong healthcare practitioners in group 2) participated in this study. Hmong community members in group 1 were asked to identify the pain pictogram that best matched a pre-recorded Hmong pain quality phrase. The practitioners in group 2 were asked to evaluate how well each pain pictogram represented the pre-recorded Hmong pain quality phrase it intended to measure. To assess the matching, we assessed agreement between the pain concept in the phrase and the pictogram intended to represent it, using group 1. A content validity index (CVI) was calculated to assess the content validity of the tool using group 2.

RESULTS

Among the community participants, 8 of the 15 pictograms were matched with the intended phrase almost perfectly, and 3 were matched by a substantial majority. There were no differences in matching by patient gender and language proficiency. Among practitioners, 11 of 15 pain pictograms met the CVI threshold of 0.70 for all three dimensions (i.e., representativeness, relevance, and comprehension).

CONCLUSION

Findings support including most of the pain pictograms in the tool but suggest specific areas for improvement.

CLINICAL IMPLICATIONS

Findings provide insights for redesigning the selected pain pictogram tool to be used in clinical settings with LEP Hmong patients.

Development and pilot testing a communication simulation training for interpreters to improve pain communication between primary care providers and patients with limited English proficiency

Context

Health disparities in patients with limited English proficiency are worsened due to scarcity of interpreter-focused communication interventions and trainings.

Objectives

To develop a high-fidelity simulation training for interpreters to use a novel pain communication tool, i.e., Pain Assessment Information Visualization (InfoViz) Tool, and evaluate interpreters' implementation fidelity during a pilot study.

Methods

This research methodology study involved training interpreters through high-fidelity simulations and assessing the implementation fidelity of 20 patient-provider visits in primary care clinics. Descriptive statistics were calculated for the assessment and fidelity. Debriefing interviews were conducted after the training and at the study completion. These were transcribed and analyzed using thematic analysis.

Results

Four interpreters completed training, requesting an average of 2.5 practice simulation studies prior to assessment (M = 54 min, score: M = 95%). Interviews revealed two themes: positive experiences and suggestions for improvement. Interpreters averaged 83% for implementation fidelity for the 20 visits. Post-study interviews revealed positive experiences and the need for refresher training.

Conclusion

The communication simulation training for interpreters is feasible, acceptable, and can ensure accurate use of the Pain InfoViz Tool during provider-patient communication.

Innovation

We applied a InfoViz Tool in pain simulations and extended high-fidelity training to medical interpreting.

Evaluating and refining a pain quality information visualization tool with patients and interpreters to facilitate pain assessment in primary care settings

Information visualization (InfoViz) tools offer a potential solution to pain communication challenges. Incongruencies in communication styles between patients with limited English proficiency (LEP), interpreters, and providers contribute to significant disparities in pain care and outcomes. This study's purpose is to evaluate and refine a culturally appropriate InfoViz pain quality assessment tool for LEP Hmong patients. We conducted a three-part iterative user-centered study with LEP Hmong, bilingual Hmong, and Hmong interpreters with (1) participatory design sessions to evaluate and refine pain infographics for inclusion on the tool, (2) card-sorting to organize the infographics to match the mental models of LEP patients, and (3) a tool assessment to identify which tool accurately represented LEP patients' mental models and was preferred in clinical settings. Fifty-five participants provided three common themes for pain infographics refinement: culturally-relevant colors, infographics resembling human anatomy, and action-specific squiggle lines. The card-sorting sessions revealed three organizational themes: sensation (n = 15; 71.4%), localization (n = 6; 28.6%), and severity of pain quality (n = 5; 24.3%). Most participants selected the localization as the most accurate tool and preferred it in clinical settings. Using a multi-step, user-centered approach resulted in a culturally appropriate pain InfoViz tool for LEP Hmong patients.

Medical interpreter-mediated genetic counseling for Spanish preferring adults at risk for a hereditary cancer syndrome

The objective of this study was to identify interpretation challenges specific to exome sequencing and errors of potential clinical significance in the context of genetic counseling for adults at risk for a hereditary cancer syndrome. Thirty transcripts of interpreter-mediated telephone results disclosure genetic counseling appointments were coded for errors by bilingual researchers, and the coders applied an overall rating to denote the degree to which the errors interfered with communication overall. Genetic counselors reviewed a subset of errors flagged for potential clinical significance to identify those likely to have clinical impact. Qualitative interviews with 19 interpreters were analyzed to elucidate the challenges they face in interpreting for genetic counseling appointments. Our analysis identified common interpretation errors such as raising the register, omissions, and additions. Further, we found errors specific to genetic counseling concepts and content that appeared to impact the ability of the genetic counselor to accurately assess risk. These errors also may have impacted the patient's ability to understand their results, access appropriate follow-up care, and communicate with family members. Among interpreters' strengths was the use of requests for clarification; in fact, even more use of clarification would have been beneficial in these encounters. Qualitative interviews surfaced challenges stemming from the structure of interpreter work, such as switching from medical and nonmedical interpretations without substantial breaks. Importantly, while errors were frequent, most did not impede communication overall, and most were not likely to impact clinical care. Nevertheless, potentially clinically impactful errors in communication of genetics concepts may contribute to inequitable care for limited English proficient patients and suggest that additional training in genetics and specialization in healthcare may be warranted. In addition, training for genetic counselors and guidance for patients in working effectively with interpreters could enhance interpreters' transmission of complex genetic concepts.