From mandate to practice

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From mandate to practice how language access policies affect Spanish speaking patients and the health care professionals who serve them
Mason, Mondi Ailene
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292 leaves : ; 28 cm


Subjects / Keywords:
Health facilities -- Translating services -- Case studies ( lcsh )
Diffusion of innovations -- Case studies ( lcsh )
Linguistic minorities -- Medical care -- Case studies ( lcsh )
Linguistic minorities -- Services for -- Case studies ( lcsh )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 283-292).
General Note:
Department of Health and Behavioral Sciences
Statement of Responsibility:
by Mondi Ailene Mason.

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Source Institution:
|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
55609303 ( OCLC )
LD1190.L566 2003d M37 ( lcc )

Full Text
Mondi Ailene Mason
B.A., University of Florida, 1989
M.P.H., University of Northern Colorado, 1994
M.A., University ofNorthem Colorado, 1994
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements of the degree of
Doctor of Philosophy
Health and Behavioral Sciences

This thesis for the Doctor of Philosophy
degree by
Mondi Ailene Mason
has been approved
ean Scandlyn

Mason, Mondi Ailene (Ph.D., Health and Behavioral Sciences)
From Mandate to Practice: How Language Access Policies Affect Spanish-
Speaking Patients and the Health Care Professionals Who Serve Them
Thesis directed by Professor Kitty K. Corbett
Health care organizations are adopting policies and practices to meet the needs of
limited English proficient (LEP) patients and comply with the Civil Rights Act of
1964. It is uncertain which policies and practices are actually implemented and of
benefit. Using Diffusion of Innovations as a framework, this case study explored
practices used to enhance language access in a large urban medical center that
serves a diverse patient population, including many Spanish speakers. Methods
included participant observation and interviews with administrators, providers,
nursing and support staff, and Spanish speaking patients in five clinics. Key topics
included: (a) perceptions of language access by patients and employees, (b) formal
and informal strategies employed to provide meaningful language access, and (c)
results from implementing these strategies. The health care organizations formal
practices to increase language access consisted of hiring bilingual employees,
contracting with telephonic interpreter services, and hiring medical interpreters.
Despite these efforts, structural and contextual problems persisted, including: (a)
care based on inaccurate or incomplete information, (b) delays in care due to
inefficiencies in the system, and (c) language barriers throughout the clinic visit.
Other challenges included discrimination and prejudicial attitudes toward patients,
and alienation among staff To respond to LEP patients, health care professionals
employed informal strategies such as using co-workers, asking family members to
interpret, and making do with gestures to overcome language barriers. Gaps in
language access remain, and are implicated in organizational inefficiency and
potentially poor clinical care. Findings have implications for developing more
culturally competent health care organizations, and improving policies and
practices for delivering care to LEP patients.
This abstract accurately represents the content of the candidates dissertation. I
recommend its publication.
itty K. Corbett

To my mother, Marilyn Mason, who gave me roots and wings.
Y para todos los inmigrantes que cruzan las fronteras de los Estados Unidos todos
los dlas. Dios les dara la fe, las alas, y la fuerza para sobrevivir en este mundo

I would like to express my gratitude to my dissertation committee, Kitty
Corbett, Lauren Clark, Sharry Erzinger, Estevan Flores, and Jean Scandlyn for
their support and enthusiasm throughout the dissertation process. For easing my
entry into the GWMC system and for their ongoing interest in the study, I would
like to thank Terence Shea, Laura Lasater, Janna Youmans, and Linda Lenander. I
will forever be indebted to Karla Chavez for her insights and assistance during
data collection. Additionally, I would like to express my appreciation for their
transcription expertise, Judy Sartin and Kerrie Sartin, for their reviewing and
coding of interviews, Christy Ashley and Daniel Quigley, and for their editorial
assistance, Carlos Gomez, Caitlin ONeill, and Amy Wise.

1. INTRODUCTION..................................................1
The Problem of Language Access in Health Care Settings...1
Cultural Competency.......................................3
The Mandate of Language Access............................4
The Purpose of the Study..................................6
The Theoretical Framework.................................8
The Research Setting: Great West Medical Center..........10
Community Health Centers.........................12
GWMC: A Health Care System Under the Knife.......14
The Influx of Immigrants.........................16
Shortage of Bilingual Health Care Professionals..18
Navigating the GWMC System...............................20
A Patient Encounter..............................20
Beyond the Patient and the Provider..............23
The Organization of the Dissertation.....................24
2. REVIEW OF THE LITERATURE....................................27
Growth of Populations with Limited English Proficiency...28
Culturally Competent Health Care Systems.................29
Prejudice and Discrimination.....................32
Asymmetry of Knowledge and Power
Between Patients and Providers...................36
Culture and Ways of Communicating About Health...38
Language Barriers in Health Care.........................42
The Ethics of Using Informal Communication Strategies....43
Language Access Policies.................................48
The Cost of Language Access versus Language Barriers.....51
Community Health Centers.................................53

3. THE THEORETICAL FRAMEWORK.........................................55
Attributes of Innovations......................................56
Communication Channels.........................................59
Innovation Decisions...................................60
Innovativeness of an Individual or Unit of Adoption....62
The Rate of Adoption...................................63
Social System..................................................65
Innovations in Organizations...................................67
The Importance of Language Access Innovation Research..........65
Critical Medical Anthropology: The Power
and Politics of Language Access................................69
4. METHODOLOGY.......................................................71
A Case Study...................................................71
Key Informants.................................................72
Rationale for the Research Site................................72
Gaining Entree.................................................74
Being an Employee of GWMC......................................78
Rationale for the Focus on Latinos.............................80
Description of the Study Design................................81
Participant Observation................................82
Semi-Structured Interviews.............................84
Changes in the Study Design............................85
Study Participants.....................................87
Health Care Professionals.........................88
LEP Patients......................................89
Hiring a Research Assistant............................89
Analysis Techniques............................................91
5. SETTING THE SCENE: SITES AND SAMPLES..............................98
Clinics with a History of Serving Spanish Speaking Patients....99
Wesley Community Health Center.........................99
Hamilton Community Health Center......................102
Clinics Transitioning into Serving Spanish Speaking Patients .103
Parker Community Health Center........................103
Eagleton Community Health Center......................105
The Center for Acute Pediatric Care...........................106

The Study Sample...............................................110
Limited English Proficient Patients...................110
Health Care Professionals.............................112
6. THE PROBLEM OF LANGUAGE BARRIERS..................................115
Inefficiencies in the System...................................116
Delays in Receiving Care..............................116
Language Barriers at Every Level...............................119
Interactions with Nursing Staff and Support Staff.....123
Interactions with Providers...........................126
Interactions with the Pharmacy........................130
A Critical Incident.............................132
Problems with Referrals...............................133
Signage and Other Written Information.................135
Form Inconsistency..............................135
Lack of Signage.................................136
Pharmacy Labels.................................137
Care Based on Inaccurate or Incomplete Information............138
Prejudicial Attitudes and Discriminatory Behavior..............140
StafF-to-Patient/Patient-to- Staff T ension...........141
Patient-to-Patient Prejudice..........................144
Staff-to-Patient Prejudice............................146
A Critical Incident.............................146
Anxiety and Alienation Among Staff.............................149
OVERCOME LANGUAGE BARRIERS........................................151
Formal Strategies Implemented by GWMC..........................151
A Language Access Policy..............................152
Medical Interpreters..................................153
The Language Line.....................................158
Forms and Other Written Materials.....................159
Informal Strategies Implemented by Individuals.................161
Pulling a Bilingual Employee........................163
Family Member as Medical Interpreter..................164
Getting the Gist and Making Do........................166

The Language Access Mandate.............................169
Problems with GWMCs Language Access Policy.................171
Little Policy Enforcement or Oversight..........175
The Language Line is The Last Resort......................177
Clinical Encounter Structure....................179
Lack of Confidence in Interpreters..............180
Preference for Face-to-Face Communication.......181
Language Line Usage and Hiring Medical Interpreters.186
Bilingual Employees and Medical Interpreters............186
The Problem with Informal Strategies....................193
Finding Solutions to the Problems.......................197
9. CONCLUSIONS AND RECOMMENDATIONS............................197
Language Access at GWMC.................................197
Power and the Uneven Distribution of Care of LEP Patients...201
Government and Health Care Systems..............201
Health Care Systems and Health Care Professionals...204
Health Care Professionals and Patients..........205
The Mandate and The Clinical Reality....................206
Creating a More Culturally Competent System.............209
Limitations of the Study................................212
Finding Solutions to the Problems.......................214
Hiring More Bilingual Employees.................214
Speaking Spanish: A Skill to be Valued..........216
Teaching Employees Spanish......................219
Forms, Signage, and Educational Materials.......220
Teaching Patients English.......................222
Future Areas of Research................................223
A. ACRONYM GLOSSARY....................................225
B. PSEUDONYM GLOSSARY..................................228

G. PATIENT INTERVIEW GUIDE.................274
LANGUAGE LINE POLICY....................278

4.1 Template Analyses Technique...........................................92
7.1 The Order of Accessing Interpreters....................................152

2.1 Federal Policies Related to Language Access........................49
3.1 Attributes of the Diffusion of Innovations Theoretical
Framework as They Relate to Language Access........................57
3.2 Stages of the Innovation Process..................................66
4.1 Clinic Presentations to Describe Study.............................77
4.2 Eligibility Requirements..........................................87
4.3 Language Access Practices by Clinic...............................93
4.4 A Priori Codebook.................................................96
5.1 Clinic Information at a Glance.................................... 99
5.2 Sociodemographic Characteristics of Patients......................111
5.3 Sociodemographic Characteristics of Health Care Professionals.....113
5.4 Health Care Professionals Interviewed............................114
6.1 Telephone Access By Clinic........................................119
6.2 Potential Areas for Communication Breakdown in the Clinics.......120
6.3 Number of Spanish Speakers in Ancillary Services.................130
7.1 How Patients Communicate in the Clinic............................162
8.1 The Attributes of GWMC Innovations................................185

The Problem of Language
Access in Health Care Settings
The surge of immigrants and refugees over the past 30 years has brought a
proliferation of languages and cultures to the United States. It is estimated that
there are now 19 million limited English proficient (LEP) people living in this
country (Flores et al. 2003). People with limited English proficiency cannot speak,
read, write, or understand the English language at a level that permits them to
interact effectively (Office for Civil Rights, 2000).
In health care settings, LEP patients encounter language barriers at nearly
every level (Perkins et al. 1998) and are often excluded from programs, experience
delays or denial of services, or receive care and services based on inaccurate or
incomplete information (OCR, 2000). Both structural and contextual barriers in
health care systems cause differences in the care these patients receive (Institute of
Medicine, 2003).
Structural barriers, based on the dominant Anglo cultures paradigm,
include availability of services and the ways in which systems are organized and
financed. For example, health care organizations may lack the resources,

knowledge, or the institutional priority to provide interpretation and translation
services. Contextual barriers are embedded in interactions between patients and
health care professionals. These barriers include the health care professionals
biases or prejudices against racial and ethnic minorities, differences in medical
knowledge and what is expected during the course of a medical encounter, and
greater clinical uncertainty when interacting with minority patients (Ventres &
Gordon, 1990; Institute of Medicine, 2003).
These structural and contextual barriers negatively affect care for many
racial and ethnic minorities, especially for LEP patients (Chang & Fortier, 1998;
Timmins, 2002). The inability to communicate with health care professionals
undermines trust in the quality of medical care received, leads to delays in seeking
care, and decreases the likelihood of appropriate follow-up (Brach & Fraser,
2000). A recent Robert Wood Johnson report states, as many as one in five
Spanish speakers do not seek health care due to language barriers (Institute of
Medicine, 2003). Other studies have found that when language and cultural
barriers are present, patients receive less information about therapeutic regimens
and understand less of the medication instructions (Baker et al. 1996; Shapiro &
Salzter, 1981). And, patients receive less preventive care and are less likely to
keep subsequent appointments (Woloshin et al. 1997). Patients with limited
English proficiency are also more likely to receive inaccurate information that
could potentially result in negative clinical consequences (Flores et al. 2003).

Creating culturally competent healthcare organizations can, at a minimum,
decrease communication barriers with patients and help alleviate health disparities
(Anderson et al. 2003).
Cultural Competency
In the face of growing diversity in patient populations, health care
organizations around the nation are grappling with how to be more culturally
competent. Cultural competence in health care describes the systems ability to
provide care to patients with diverse values, beliefs, and behaviors (Betancourt et
al. 2002). Much of the impetus driving these efforts is increased governmental
pressure to provide culturally and linguistically appropriate services in federally
funded health care agencies. Language access is a sine qua non for a culturally
competent organization. Although some organizations historically have provided
interpreter services, there is a growing emphasis on providing cultural competency
training for employees and adopting more strategies (e.g., language line,
translation of written material) to enhance communication between health care
professionals and LEP patients (Office of Minority Health, 2000).
Building a culturally competent health care system is complex. Sources of
mistrust and disparities in health care systems run deep and are rooted in historic
and contemporary inequities. Addressing these issues involves participants at
many levels, including: governmental agencies, health care organizations, health

care professionals, and the communities where patients reside. Strategies to
improve cultural competency and increase health care access for LEP patients need
to encompass micro-level and macro-level issues. Micro-level issues are more
practice-based and concern the clinical encounter and interactions between
individuals. Macro-level issues are societal inequities that permeate the health
care sector and perpetuate the disparities in health among racial and ethnic
minorities (Waitzkin, 1991).
The Mandate of Language Access
With the dramatic increase in immigrant populations in the United States,
one of todays civil rights challenges is access to health care for people with
limited English proficiency. In 1998, the Clinton administration focused
considerable attention on improving the health status of racial and ethnic
minorities in the United States through The Initiative to Eliminate Racial and
Ethnic Disparities in Health. One of the principal tools used in addressing health
disparities is Title VI of the Civil Rights Act of 1964 (Perez, 2003). Title VI
mandates that:
No person in the United States shall, on the grounds of race, color
or national origin, be excluded from participating in, be denied
benefits of, or be subjected to discrimination under any program or
activity receiving Federal financial assistance. [Emphasis added]

The United States Department of Health and Human Services (HHS) has
long recognized that national origin in this piece of legislation encompassed
linguistic accessibility to health care. Moreover, the Office for Civil Rights (OCR)
within HHS has consistently interpreted Title VI to mean that health care
organizations must provide qualified interpreter services and translated materials
for patients at no cost (Perkins et al. 1998). The failure to provide effective
language assistance is tantamount to national origin discrimination. Because
federal funding is pervasive in health care, nearly every health care organization in
the nation is bound by the Title VI mandate. If organizations are found to be out
of compliance with the law, they are subject to penalties that may result in the loss
of federal funding.
Despite numerous federal, state, and private sector agencies passing
legislation, creating regulations, or developing recommendations to address the
provision of language services in health care since 1964, the rights of LEP persons
have remained on the periphery until recently. Now, health care organizations are
adopting a wide range of policies and practices in reaction to these mandates.
Much of the impetus behind the renewed energy toward the development or
enhancement of language access policies and practices in health care settings
comes from the 1998 and 2000 releases of an OCR Policy Guidance entitled,
Title VI of the Civil Rights Act of1964; Policy Guidance on the Prohibition

Against National Origin Discrimination As It Affects Persons with Limited English
Proficiency. The complete document can be found in Appendix C.
According to the Policy Guidance, the key to meaningful language access
is an exchange of information that takes place in a language and context clearly
understood by patients. Under Title VI of the Civil Rights Act, health care
organizations must ensure patients are given adequate information, are able to
understand the services and benefits available, are able to make informed choices,
and receive services for which they are eligible. Health care organizations must
also ensure that LEP patients can effectively communicate the relevant
circumstances of their situation (OCR, 2000). OCR recommends practices health
care organizations can implement in order to comply with the law.
The Purpose of the Study
This thesis explores how OCR-recommended practices to enhance
language access are implemented. These practices include: (a) hiring bilingual
staff, (b) hiring medical interpreters, (c) contracting with a telephone interpreter
line, and (d) translating written materials into other languages. The study assessed,
(a) perceptions of language access by patients and employees, (b) what formal and
informal strategies are employed to provide meaningful language access, and (c)
what results from implementing these strategies.

Ethnography was employed in this study to explore how Great West
Medical Center (GWMC) implements language access policies and practices.
Using a naturalistic approach, qualitative data were collected over a nine-month
period in five clinics in a large metropolitan area in 2002. The purposes of this
analysis were to describe the factors that determine how, or if, mandated practices
are implemented, and to assess consequences of these practices on the delivery of
meaningful language access to LEP patients.
Data were collected from GWMC administrators, and those who are
affected daily by the implementation (or lack of implementation) of practices to
increase language access in a clinical encounter, health care professionals and LEP
patients. Data describing their perspectives and experiences were obtained
through semi-structured interviews. Participant observation was used to acquire
information about the flow of the clinics and health care professionals interactions
with LEP Spanish speaking patients.
The findings from this study will contribute to a greater understanding of
(a) how language access policies and practices are implemented for LEP Spanish
speaking patients at the clinical practice level at GWMC, and (b) how language
access policies and practices affect LEP patients and the health care professionals
that serve them. The findings of this study also contribute to the national dialogue
about how best to provide culturally and linguistically appropriate services in
health care settings.

This study is a first step toward determining how policies and practices
recommended by the OCR are implemented by health care settings and how these
practices affect meaningful language access for LEP patients and the roles of
health care professionals. Only when we determine how, or if, these practices are
implemented can we begin to assess what works for LEP patients and the health
care system that serves them. Furthermore, it is only then that we can determine if
a federally mandated policy is effective in accomplishing its goals.
The Theoretical Framework
This study is grounded in the Diffusion of Innovations, a theory developed
by Everett M. Rogers. This theory provides a framework to study how and why
innovations are adopted or rejected and what consequences and changes occur.
Historically, diffusion research explained social change in a given society because
of the introduction of innovations from another society (Rogers, 1995). Since
then, diffusion research has stretched across numerous disciplines.
Anthropological studies have shown that planners and officials in charge of the
development of well-meaning programs sometimes fail to fully account for the
cultural values of potential adopters (Justice, 1986). According to Rogers (1995),
the use of ethnographic methods of participant observation and personal interviews
results in a high degree of understanding of the respondents points-of-view and in
conveying their perceptions of the diffusion of the innovation. This perspective

helps researchers overcome the pro-innovation bias that often occurs in diffusion
research and provides a unique understanding of the consequences of innovation.
In the context of this study, innovations were the policies and practices
implemented by GWMC to provide meaningful language access to LEP patients.
The rationale for using diffusion of an innovations is that this theoretical
framework is essentially striving for a type of social change, the process by which
alterations occur in the structure and function of a social system. Congruently, the
Civil Rights Act was enacted to create a societal change from a history of racial
injustice and inequality to fair and equitable treatment of people from different
backgrounds with respect to public accommodations, jobs, education, and health
care. In this study, the area of change in the social system is language access for
LEP patients in a health care system.
Because language is an integral part of culture, and language access
innovations affect the health care culture, I could not begin to explore the
perceptions and experiences of health care professionals and patients regarding
language access without adequately considering sociocultural information. In the
context of this study, the cultures to be considered are the patients and the
organizational culture of the health care system. When both cultures are not
considered, practices fail, are not used to their fullest potential, and lead to
unanticipated consequences.

Attributes, or characteristics, that are key in the adoption or rejection of
innovations provide a basis for understanding why GWMC policies and practices
(or innovations) are, or are not, implemented. The diffusion theory also provides a
mechanism for examining organizational innovativeness and insights into the
processes and behaviors of organizations as they change.
Although beneficial in providing an objective approach in which to
examine the diffusion of innovations in health care systems, the theory does not
take into account subtler structural and contextual challenges that affect the
interaction between health care professionals and LEP patients. Practices
implemented within the GWMC system were examined within a broader context
of historical and current discrimination that exist within a health care sector in an
increasingly culturally pluralist society. Additionally, the asymmetry of power
present at all levels within health care systems between patients and health care
professionals, providers and subordinates, the federal government and funding
recipients is also considered.
The Research Setting: Great West Medical Center
Founded in 1860, GWMC is a vertically integrated public health care
system. The term vertically integrated refers to the organizations ability to
provide health care across multiple levels (e.g., emergency care, primary
prevention, subspecialty care) to patients. The Medical Center houses 349

licensed inpatient beds, behavioral health services, and a regional trauma center. It
also operates the citys 911 medical emergency system, paramedic services, and an
emergency residency program. Other services provided by GWMC include a
public health department, dental clinics, pharmacy services, a poison center, a 24-
hour Nurse Line, adult and pediatric urgent care centers, a health maintenance
organization, and inpatient and outpatient services for the states Department of
The Medical Centers main campus covers three and one-half square city
blocks and is made up of an assortment of new and old red brick buildings just
southwest of downtown. The campus is located where five ethnically diverse
residential neighborhoods intersect.
GWMCs mission is to:
Provide access to quality preventive, acute and chronic health care
for all citizens of this city, regardless of ability to pay;
Provide high-quality emergency medical trauma services to citizens
of this city and the region;
Fulfill public health functions as dictated by the citys Charter and
the needs of the citizens of this city;
Provide health education for patients and participate in the
education of the next generation of health care professional; and
Engage in research that enhances our ability to meet the health care
needs of patients of the GWMC system.

Community Health Centers
GWMCs Community Health Services (CHS) Division reflects the
historical mission of the United States medical safety net system in that it has nine
community health centers in the citys medically underserved neighborhoods and
eleven school-based clinics. [It] has been a model for the nation for years (D.H.,
2003). Community Health Services serves over 20% of the citys population each
year. The majority of patients served are ethnic minorities; approximately 50% are
Latino. It is estimated that over 40% of the 400,000 outpatients served by the
community health centers have limited English proficiency.
The United States Public Health Service 330 grant funds primary
care and this agency... its under HRS A [Health Resources and
Services Administration] to fund CHS [community health services]
throughout the country all the way from Alaska to Puerto Rico and
the Virgin Islands. There are like 2,200 community health centers
in the country. We are the largest network of community health
centers and the second oldest. The Bureau of Primary Health care
receives federal dollars, tax-based dollars, to provide a grant to
health centers so they can provide services, especially to
underserved and uninsured individuals on a sliding fee basis. They
do expect those centers to collect monies from third party payers
and insurance companies to the extent patients are insured. But this
gives health centers the opportunity to truly serve the underserved
and uninsured.
- CHS Administrator
GWMC is striving to create a diverse workforce to be reflective of the
communities it is serving. It is estimated that 24% of the 2,455 employees in CHS
are Latino, with the majority of these employees working in clerical or support

staff (14%) and clinical professional positions (i.e., nurse or medical assistant)
(10%). A recent study estimated that 54% of GWMC providers are bilingual
(Latin American Research and Service Agency (LARAS A), 2002), but it is
unknown how many employees are bilingual (English/Spanish). Collecting data
on employees language abilities can facilitate a better understanding of the hiring
and placement needs of the organization and lead to becoming a more culturally
competent organization. One-third of the employees participating in this study
identified themselves as bilingual.
GWMC has been providing some interpreter services to its ethnically
diverse patient population for over 25 years. Twenty years ago, the hospital was
serving primarily Vietnamese patients. At that time, GWMC had volunteer or
community-based Vietnamese interpreters available for its LEP Vietnamese
patients. Within the last decade, the Spanish speaking patient population has
become the dominant language group that the hospital and its clinics serve.
Since the release of the 2000 OCR policy guidance, GWMC has placed a
renewed emphasis on providing culturally and linguistically appropriate services.
Although a variety of strategies have been implemented, the primary focus has
been on the development of practices to increase language access for LEP Spanish
speaking patients. These practices have included:
1. hiring bilingual (English/Spanish) employees,
2. hiring medical interpreters,

3. contracting with a telephone interpreter service, and
4. creating written educational materials in Spanish.
Before discussing how these language access practices fit into a health care
system, it is important to consider the context in which the system exists.
According to Thompson (1998), context is those factors in the environment which
impact and influence the development, modification, and daily activities of a
program. The following sections will briefly discuss financial pressures on the
public health system, the influx of immigrants, and the shortage of bilingual health
care professional.
GWMC: A Health Care System Under the Knife
Public health care systems are in trouble. Systems around the nation like
GWMC are a safety net organization and have the primary responsibility for
taking care of the indigent and uninsured people in their respective cities and
counties. Many of the people that fall under the care of such institutions are LEP
immigrants and refugees. In 2002, the majority of GWMCs $400 million annual
operating budget was funded by Medicaid, Medicare, and private insurance
(Brovsky, 2003). Thus far, in 2003, GWMC has provided $214 million in
uncompensated care to people without insurance (Scanlon, 2003). This figure is
projected to increase by $40 million in 2004. GWMC is the number one provider
of uncompensated care in the city and county. By comparison, another area

hospitals uninsured patient population is 8% (Scanlon, 2003). Additionally,
during 2001, a large managed care organization decided to no longer accept
Medicaid patients and the universitys hospital cut the number of Medicaid
patients they would accept to 10%.
With these shifts in responsibility, GWMC continues to report having
financial problems and even hinted at potential closure during 2002. To allay
shortfalls, GWMC changed its rules for co-payments and enrollment for all
patients. Co-payments increased for all patients, especially the uninsured. Now,
all eligible patients are required to enroll into the states indigent care program
before being seen at the clinic for non-emergency conditions.
This bureaucratic layer creates a structural barrier patients have to
maneuver through before receiving care. As the rules changed during 2002, it was
common for patients to arrive at the clinic for their appointment only to be turned
away because they did not have their co-payment at the time of service. This
change was a grave concern for providers. They wondered how this change would
affect the clinics and the health and well-being of patients who could not afford the
increase in fees. Finally, in 2003, GWMC cut $15.7 million by laying-off 122
employees and closing clinics (Gabow, 2003). Given the drastic shortfall in
resources, it is important to consider how organizations in constant financial
distress afford to provide meaningful language access under an unfunded mandate.

Institutional policies for insurance eligibility and the co-payment
challenges greatly affect legal and undocumented immigrants alike. After the
welfare reform law of 1996 was passed, most legal immigrants admitted to the
United States became ineligible for welfare, public health insurance, and other
major federal benefits. Recently, the states legislature passed legislation to cut
Medicaid funds even to legal immigrants (Pankratz, 2003). Undocumented
immigrants, who face further restrictions on non-citizen eligibility for Medicaid
and the state Childrens Health Insurance Program, are even more likely to have
limited access to health insurance benefits or a usual source of health care than
legal immigrants (Reardon-Anderson et al, 2002). Very limited reimbursement for
language access services exists under Medicaid. However, now that legal and
undocumented immigrants do not even qualify for this insurance, GWMC, like
other public health institutions, has to foot an even larger bill for language access
than they did before.
The Influx of Immigrants
The increase in the number of Mexican immigrants means GWMC will
continue to be pressed to become more culturally competent. To do this
appropriately, GWMC will need to make language access a priority within its
already tight budget.

As mentioned previously, GWMC has a long history of serving immigrant
populations. In the late 1800s, Italians and Germans dominated the area. By the
1970s, interpreter services were developed for Vietnamese refugees. Today,
Spanish speaking Mexican immigrants outnumber all other language groups.
According to GWMC administrator and provider perceptions, GWMC is
the best show in town when it comes to serving Spanish speaking patients.
Word-of-mouth advertising and announcements on Spanish language radio have
been a powerful influence on the choice of Spanish speaking populations when
seeking health care.
GWMC providers frequently shared their perception that there is a
pipeline to this city from Mexico. They felt that many of their patients come
from Mexico with the specific intention of seeking health care at GWMC only to
return to Mexico once they have received their treatment and medications. One
provider shared:
[GWMC] advertises, so they encourage people to come here and
thats just sort of word of mouth.. .People literally get off the bus
and come here. Once I had a lady who had been in Mexico, she had
fallen and complained of a severe headache and her doctor down
there told her she had to two weeks to live. She had a CT scan
check and had a subdural hematoma. He told her you need an
operation but she didnt want to get it done down in Mexico, so he
gave her some Decadron, thats a steroid to inject in case she started
feeling like she was going to pass out or anything. She thought,
Oh he told me two weeks so I have two weeks to go to GWMC,
so I literally saw her in the clinic about 10 days later. She ended up
getting neurosurgery to get her hematoma evacuated and she did
okay, but its just amazing how people come all the way up here,

were 700 miles from the border and people still come up here... for
some reason there is a big pipeline to come up here.
It is uncertain if this is truly the case. GWMC does have a reputation among the
Spanish speaking community for having bilingual employees. Perhaps Spanish
speaking populations feel they can get their needs met in their primary language
while residing in this area. However, it has been documented elsewhere that
Mexican immigrants are hesitant to seek health care in the United States due to
mistrust of the system (Valdes, 1996).
Shortage of Bilingual Health Care Professionals
One strategy to provide meaningful language access is hiring or promoting
bilingual employees. Recognizing the potential that already exists in the GWMC
workforce may be at least part of the answer to providing culturally and
linguistically appropriate services to its patients. Nationwide, demographics of
health care professionals do not match the demographics of the population at large
(Riddick, 1995). Because of the large numbers of Spanish speaking patients seen
at GWMC, there is a preference for hiring Spanish speaking employees.
Currently, the majority of bilingual employees are in para-professional roles (e.g.,
Medical Assistant) and front desk or enrollment specialist positions. The value of
these employees is already recognized, at least on one level.

Definitely here when were recruiting support staff, boy if
somebody says they speak any Spanish, we're grabbing them, you
know and because it just makes a big difference.
- Provider
What may not be recognized is that these para-professional employees may be a
remedy for the lack of qualified bilingual providers and other medical
professionals in the hiring pool. Looking within and providing more training or
prospective educational reimbursement for the dedicated support staff that
currently works in the system may be part of the solution.
I have support staff in my unit that are bilingual and come from
Spanish-speaking only families, but because of many different
socioeconomic reasons they cant go through RN school on their
own. Going off to college or something with kids and husbands
and living on $12 an hour, its just out of their reaches. There are
people in this building that if they are able to get through RN
school, they would never, ever leave GWMC and they would have
a 35-year employment history. We dont do enough. Were not
doing anything in our community to attract nurses. GWMC has a
tuition reimbursement program, but the problem is that you dont
get reimbursed until after you go to the classes and then of course
you dont get it all reimbursed either. So, when youre only making
$12 an hour and you have 2 kids, and youre a single Mom, to come
up with $750 or $900 for a semester is an unbelievable task. They
need child care somebody to pay for it and that sounds like a lot,
but with a greater than 40% turnover in the nursing unit at GWMC
that sounds like a lot. But, if you are to have an employee that was
yours for 25 years that was proud to be an employee and dearly and
deeply was bought into the mission of GWMC, it would be well
worth the bucks. It would make much more sense than spend all
the money on orientation on all those people, just so they can get a
couple months of med-surg. experience and split.
- Practice Manager

Additionally, providing training for the para-professionals who already work in the
nations health care institutions may be part of the solution to the lack of nurses, a
crisis that is projected to reach a shortage of 20% by the year 2020 (Buerhaus et al.
Navigating the GWMC System
The social structures of all health care systems affect language access and
the diffusion of the practices that have been implemented to enhance it. The
participating clinics in this study varied, yet because they were part of the same
system they share similar characteristics. The GWMC system perpetuates the
creation of similar structures in each clinic, resulting in a patterned arrangement,
or flow, to each clinic. A theme that emerged during initial conversations with
administrators was that GWMC provides services in Spanish from registration to
pharmacy. This became one of the first areas to explore within the system to
determine if this was indeed true. To demonstrate that this perception is not totally
accurate, the following depicts a typical encounter for a LEP patient.
A Patient Encounter
The LEP Spanish speaking patient and her two children enter the clinic.
Depending on the clinic, it may or may not be evident where she needs to begin.
In this case, the clinic directory is in English, so that is not very helpful. She

establishes where she needs to go first by asking a nearby employee or patient.
Once she establishes the location of patient registration and that she needs to take a
number to begin her visit, she waits until a clerk at the registration desk calls her to
check-in. Because the registration clerk speaks Spanish, and because she already
has an appointment, this part of the clinic visit may be the easiest in terms of
communication. Assuming she has her blue card (i.e., the hospitals patient
identification card), and all of her supporting paperwork has been completed in
advance, the patient can then take her paperwork for the clinic encounter and move
to the appropriate clinic for her appointment. To facilitate her progression through
the clinic, the registration clerk may have advised her about what to do upon
arrival at her next stop.
Approaching the adult clinic desk, she may notice that she needs to leave
her forms in a box. If unsure of what to do, she may hand her forms to the front
desk clerk. The clerk may then say in English while motioning with her hand,
Put the papers in the box. or Go sit down and they will call you in a minute.
Because she does not speak English she hesitates a moment. A confused look may
cross her face, but then she moves to the box or takes a seat in the waiting area.
Because she has an appointment, once a Medical Assistant calls her name, she will
be checked-in. Check-in means being asked a series of questions about her
health. For example, Does she have allergies? Is she taking any medications?,
and Does she smoke? She is then weighed and her temperature and blood

pressure are taken. If the person who checked her in does not speak her language,
these questions may be asked using gestures or one or two words in Spanish that
are not always pronounced correctly. At this point in her clinic visit, she may or
may not fully understand what these questions mean, what she is being asked to
do, or what will come next.
Again, because she has an appointment, she is most likely be taken to an
examination room where she waits to see a doctor. Depending on how long the
delay is in the clinic, or if an interpreter needs to be called, she may be asked to
wait in the waiting room. Once she is in the examination room, a provider, who
may or may not speak her language, asks her more questions about her medical
history. If the patient and the provider are not able to negotiate some sort of
understanding of what the health issues are and how treatment should proceed, the
provider may utilize one of her children as an interpreter, may leave and try to find
someone who can interpret, or may utilize the language line. If another bilingual
employee is chosen, the patient waits in the examination room until the provider
returns with an interpreter. Or, if the clinic is busy, she will be asked to wait in the
waiting room until the interpreter arrives. Having the patient return to the waiting
room frees up the examination room to allow other patients their turn. Another
option is that while she waits for an explanation from a medical interpreter or a
bilingual employee, she may be asked to go to the laboratory for lab work or to the
pharmacy to fill a prescription. Both of these ancillary services have sub-systems

to learn and do not always have signage in Spanish to instruct patients about the
system. In addition, neither of these areas of the clinic may have an employee that
speaks Spanish.
Beyond the Patient and the Provider
What is important to note in the illustration above is that: (a) the
organization has not provided adequate signage to appropriately direct patients
who do not read English, (b) the power to establish linguistically appropriate care
is in the hands of the clinic staff, (c) the inability to communicate due to the
availability of bilingual employees results in delays for the patient, and (d) many
of the clinic contacts are beyond the patient-provider encounter. Often, studies
only examine the language barriers at the patient-provider point of contact.
However, language barriers exist within the entire system.
Patients who make multiple visits to a clinic ultimately learn the general
patterns that give regularity and stability to interactions within the clinic system.
But overall, LEP patients, especially if they are new to the system, may not
understand the whys and hows of what is taking place at almost every point of
contact within the clinic. The question becomes: how can we make the entire
clinic visit efficient so that patients can easily navigate through the system?
Things that would be very helpful that we dont usually have the
opportunity for our patients to take advantage of would be to have
bilingual support staff. So, bilingual people in registration,

bilingual people in the pharmacy, bilingual people at every point
where our patient needs to go because one thing that happens to us
by the time they get back here in the room and they realize that we
can communicate very well with them, we get asked all these
questions about their insurance, their this, their that, and we need to
help them navigate through the system. First of all, I dont have an
expertise in the insurance stuff, even after being here nine years, its
changed so much. I dont have a clue what I can really tell them to
make it concrete and helpful. Secondly, I dont have time to do
that. Im just supposed to take care of their medical and social
needs and some of the other quality of life issues that they have in
10 or 15 minutes anyway. And thirdly, I really believe its a
conflict of interest it really kind of interferes with what Im trying
to do as a provider. So, having bilingual support staff to do other
parts of the services that our patients need is really helpful.
- Provider
It is important to ask, what happens to the health professional when a LEP
patient walks in the door? If the employee speaks Spanish, the visit proceeds
smoothly. Otherwise, based on the findings in this study, employees find
strategies that help them cope. Unfortunately, these strategies sometimes result in
problems that increase the clinic inefficiencies, may compromise the quality of
care based on inaccurate or incomplete information, and intensify frustrations that
simmer below the surface.
The Organization of the Dissertation
The structure of this thesis is as follows. The rationale for this type of
study, highlighting the growing need for culturally competent services, the

increased pressures being put on public health system, and the mandate for
language access was briefly reviewed in this chapter.
Chapter 2 discusses the: (a) growth of LEP populations; (b) importance of
creating more culturally competent health systems to better serve these
populations; (c) legal, ethical, and health-related problems associated with poor
communication between patients and providers; (d) importance of considering the
power dynamics that influence interactions between the health care organization
and its employees, health care professionals at different levels within the
organization, and between health care professionals and LEP patients; and (e)
laws, regulations, and recommendations enacted to facilitate communication and
access for LEP populations.
Chapter 3 outlines the elements of the Diffusion of Innovations
theoretical framework. This chapter focuses on how the theory was used in this
study. Also discussed are the strengths and limitations of the use of this theory in
examining social change within the health care sector.
The qualitative methods used to explore the language access practices
implemented by GWMC and the subsequent analyses of the data are described in
Chapter 4.
Chapter 5 sets the scene for the study by describing GWMC, the
participating clinics, and the sample of patients and health care professionals who

The perspectives and experiences of LEP patients and health care
professionals about the consequences of poor communication are described in
Chapter 6.
Specific formal practices implemented by the GWMC system and the
informal practices put into place by health care professionals to meet the needs of
LEP patients are described in Chapter 7.
Chapter 8 examines the seriousness of problems with the practices that are
implemented in the health care system from a theoretical perspective.
Chapter 9 concludes the dissertation with perspectives about how to create
a more culturally competent organization through the implementation of strategies
at multiple levels in the health care system. Also included are patient and health
professional recommendations to facilitate more meaningful language access in the
GWMC system.

The United States has been a multicultural and multilingual society since
its inception, but the nations health care systems remain largely geared toward
serving people who speak English (Chang & Fortier, 1998; Flores, 2000; Hampers
et al. 1999; Tocher & Larson, 1999). Only recently, with the rapid resurgence in
growth of immigrant and refugee populations (Fix & Capps, 2002), the growing
political power of ethnic groups (OCR, 2000; Weaver, 1982), and the threat of
lawsuits (Perez, 2001; National Council on Interpretation in Health Care, 2002)
has language access become a critical issue for health care organizations around
the country.
This chapter discusses, (a) the growth of limited English proficient (LEP)
populations at the national, state, and local levels, (b) the importance for culturally
competent services, (c) patient-provider communication, (d) the health
consequences of language barriers, and (e) the legal, ethical, and regulatory
aspects of language access that have resulted in new or enhanced policies and
practices for health care organizations.

Growth of Populations with
Limited English Proficiency
The number of different languages spoken in the United States has
increased dramatically (Perkins et al. 1998). According to the United States
Census (2000), almost 47 million (17.9%) people speak a language other than
English as their primary language at home. Over 28 million (10.7%) people in the
United States speak Spanish, making it the most common language spoken in the
nation other than English. Of these Spanish speakers, over 13 million (5.2%) self-
report that they speak English less than very well.
Latinos are the largest ethnic minority in the state where Great West
Medical Center (GWMC) is located. Over 10% of the Latinos in the state speak
Spanish as their primary language at home and half report that they speak English
less than very well (United States Census, 2000). The number of Latinos grew
by an estimated 64% and makes up 17% of the population (Flores et al. 2003). It
is estimated that 735,601 Latinos live in the state, making it eighth among new
growth states. New growth states are defined as those states that have not
received significant numbers of new immigrants for over a century until recently.
Twenty-seven percent (139,498) of the county population served by
GWMC speaks a language other than English at home, with almost 15% stating
they speak English less than very well. Of those who speak Spanish (21%), a

little over half (12% or 62,690) report that they speak English less than very well
(United States Census, 2000).
Because of the national, state, and local growth of Latino populations, this
study focused on examining language access for Spanish speakers. This does not
diminish the importance of language access for other growing LEP populations
(i.e., Russian and Vietnamese). It can be inferred that since the outcomes of this
study demonstrate that the practices implemented for Spanish-speakers are
insufficient, communication problems encountered by patient who speak other
languages may be magnified.
Culturally Competent Health Care Systems
As the United States becomes more racially and ethnically diverse, health
care systems are trying to respond to varied patients perspectives, values, and
behaviors about health. The field of cultural competency has emerged in an effort
to reduce health disparities among and increase health care access for diverse
patient populations. Cultural competence is defined as a set of congruent
behaviors, attitudes, and policies that come together in a system, agency, or among
professionals that enable effective work in cross-cultural situations (Anderson et
al. 2003; Office of Minority Health, 2000). The ultimate goal of cultural
competence in health care systems is to deliver the highest quality of care to every

patient, regardless of race, ethnicity, cultural background, or English proficiency
(Betancourt et al. 2002).
Currently recommended strategies for creating more culturally competent
organizations and systems extend beyond the early approaches of just providing a
training. These strategies include: (a) developing programs to recruit a racially
and ethnically diverse work force in health care, (b) assessing the system by
conducting patient satisfaction surveys, integrating community perspectives into
planning, and collecting data on race/ethnicity and language preference in order to
provide appropriate interpreter services and health information reflective of the
community, (c) enforcing the federal mandate of Title VI, (d) conducting
standardized and evidence-based cross-cultural education and training at all levels
within the system and should incorporate curricula related to socioeconomic facts,
communication skills, mechanisms for addressing racism and bias, and patient
empowerment, and (e) developing program to help patients navigate the health
care system (Anderson et al. 2003; Betancourt et al. 2002; Office of Minority
Health, 2000).
An integral component of cultural competence is providing linguistically
appropriate care. Language is a mechanism by which cultural meaning is
transferred. Anyone who has tried to learn another language realizes how complex
this is. Directly translating the literal meaning of words from one language to
another may be helpful with communication at its simplest form. What one

quickly realizes, however, is that a combination of words within a particular
context takes on specific cultural meanings, thus requiring complex layers of
understanding. As a result, communication between patients and providers where
language discordance exists is not effective in conveying crucial health beliefs,
core values, or a true description of symptoms (National Alliance for Hispanic
Health, 2000). Failure to understand a patient can have significant health
consequences, create barriers to accessing care, and undermine trust in the quality
of the medical care received.
The keys to true cultural competence require not just language proficiency,
but an understanding of the communities being served. This requires knowledge
of the sociocultural influences mentioned above, but also the historical and current
context of oppression and exploitation in which these communities live. Models
for cultural competency call for addressing more macro-level societal issues, not
solely micro-level clinical encounter issues. To do this, institutions and
individuals need to consider race/ethnicity as social and political constructs
beyond a biologic concept (Omi & Winant, 1994; Jones, 2000). Doing this leads
to a better understanding about how exposure to racial ideology, political
exclusion, and economic discrimination by the dominant Anglo race and its
institutions can affect a persons social and cultural identity (Muntaner, 1999).
Although attempts to mandate language access in health care organizations
through federal and state policies and through regulatory agencies have increased,

language access is far from perfect and communication barriers still exist between
patients and their health care team. The reasons for this are many. According to
Ventres and Gordon (1990), contextual barriers contribute to poor communication
in health care, especially among underserved populations. In their view,
contextual barriers consist of (a) prejudices providers hold toward ethnic minority
patients, (b) asymmetry in knowledge and power between providers and patients,
and (c) differing perceptions of meaning and ways of communicating about health
and illness. Each of these issues will be briefly discussed below.
Prejudice and Discrimination
Intolerance of immigrants, cultural stereotypes, bigotry based on race and
ethnicity, and class hatred work to the disadvantage of LEP patients. Perez (2001,
pg. 217) states, we cannot begin to eliminate racial and ethnic disparities by
ignoring the role of discrimination. Physicians have been found to hold
prejudicial views about patients. Price and his colleagues (1988) found that one-
fourth of family practice residents in Ohio thought people with a lower
socioeconomic status are poor because of laziness, and one-fifth believed that most
poor people live well on government assistance. Schulman and his colleagues
(1999) found that a patients race and gender influence physician treatment
decisions related to cardiac catheterization. When patient characteristics were
studied to determine if they influenced physician behavior, Hooper et al. (1982)

found that physicians conducted better interviews with and demonstrated more
empathy toward Anglo patients than to Latino patients.
Discrimination and prejudice, along with exclusionary societal practices,
have consequences. A majority of the medical residents Price et al. (1988) studied
believed that poor patients are less knowledgeable than others about their illnesses,
less likely to understand medical care directions, and less compliant with their
medical regimens. In a meta-analysis, Hall (1988) found that minority and low
socioeconomic patients receive less information about their conditions, less
positive or reinforcing talk, and less talk or communication in general than do
patients in higher socioeconomic levels.
Jones (2000) outlines three levels of racism: institutionalized, personally
mediated, and internalized. The first level, institutionalized racism, is defined as
differential access to the goods, services, and opportunities of society by race.
This type of discrimination can range from very subtle to very blatant. An
example of blatant institutionalized discrimination is called redlining. The
concept of redlining is when agencies willfully implement a policy that
differentiates what services will be provided to certain communities or people.
Though most frequently associated with housing and mortgage lending, there are
instances where redlining exists in the health care setting. For example, a policy at
a South Carolina hospital requiring women in labor to communicate in English if
they wanted an epidural is redlining (Perez, 2000).

The English only movement as another form of racism. This movement
promotes legislation that restricts or prohibits the use of languages other than
English by government agencies and, in some cases, private businesses. Twenty-
three states, including this state, have passed English only laws. These laws
prohibit other languages than English in schools, courts, and voting services and
could potentially affect agencies that are funded by the Department of Health and
Human Services (HHS). According to the American Civil Liberties Union (1998),
English only laws limit the rights of individuals with limited English proficiency.
They also perpetuate false stereotypes of immigrants and non-English speakers.
While one may hope and expect immigrants and refugees in the United States to
learn English, learning a language is a slow process. During this learning process,
people should be afforded the opportunity of meaningful access to health services.
The second level of racism is personally mediated racism. It is defined as
prejudice and discrimination, where prejudice means differential assumptions
about the abilities, motives, and intentions of others according to their race, and
discrimination means differential actions toward others according to their race. An
example of this type of racism is seen in anti-immigrant sentiments based on false
stereotypes of immigrant groups. These sentiments may play a large role in the
lack of funding or enthusiasm for implementing programs that would improve
language access to health services.

Recently, when adults in the United States were asked whether immigrants
to this country should be prepared to assimilate, 88% of those who completed
some high school, 84% of high school graduate and 76% of college graduates said
yes (Sandor, 1994). While cultural homogeneity has never been achieved and
cultural differences have always existed, ethnic minority groups have often been
marginalized and the institutions of American society have largely been insensitive
and unresponsive to the needs of these populations.
The third level of racism outlined by Jones (2000) is called internal
racism. This concept is defined as acceptance by members of stigmatized
races/ethnicities of negative messages about their own abilities and intrinsic worth.
Although numerous factors are at play in regard to language access for LEP
patients (e.g., cultural differences in seeking services, fear, and mistrust of
governmental systems), the internalization of negative messages could be one of
them. Perez (2001, pg. 219), advocates for educating patients in addition to health
professionals about language access in relation to civil rights. He states, All too
frequently victims of discrimination in the health care setting do not even know
they have been discriminated against. They are simply grateful that somebody
looked at them.

Asymmetry of Knowledge and Power
Between Patients and Providers
A central but often unspoken dynamic in cross-cultural medical encounters
is about power. Because the health care system is reflective of social relations in
the larger American society, it is important to include this underlying variable in
the discussion about language access. Seen as a critical variable in health policy
and programming (Singer, 1998), power is defined as the capacity to produce
desired effects on others (Pinderhughes, 1989).
In the provider-patient relationship, the balance of power is inherently with
the provider. This patient-provider imbalance does not automatically place a
negative or positive value on that asymmetry (Pappas, 1990). An example of
asymmetry is that providers are socialized to speak another language, the language
of disease, and use specific technical knowledge. This specialized knowledge may
be an unintentional way of gaining power over the patient, regardless of what
language is spoken. When analyzing patient-provider dyads, physicians frequently
are found interrupting their patients, asking closed-ended questions that require
only a yes or no answer, and initiating over 90% of all questions in an encounter
(Ventres & Gordon, 1990). The use of this type of communication is a way a
provider can quickly get the information needed for a diagnosis. Patients are
dependent on their providers, but the provider is presumably acting with the
patients best interest in mind (Pappas, 1990).

Having a medical interpreter in the room with the provider and the patient
shifts the power and control. The patient and provider are both dependent on the
interpreter to create a setting that allows for the exchange of information that is
central to successful patient-provider interactions (Weaver, 1982). This third
party, who may understand the patient from a social and cultural perspective, may
be a disruption to the dyad whether there is effective communication or not. For
example, the patient may give power to the interpreter by only looking at her
rather than facing the provider when speaking. Or, the provider and interpreter
may behave in such a way as to not allow time for the formation of a bond with the
patient due to time limitations, thus limiting the amount and quality of the
information elicited from the patient (Weaver, 1982).
The power, or lack of power, inherent in patient and provider roles and in
their cultural groups status can affect the clinical process and health outcomes
(Penderhughes, 1989). When an undocumented patient is dependent on a person
in a bureaucratic system, fear and mistrust may relate not only to communication
issues, but also to how much the patient can safely disclose. During clinical
encounters, a patients sense of powerlessness may be reinforced. Empowering
patients requires the use of strategies that enable them to experience themselves as
competent, valuable, and worthwhile both as individuals and as members of their
cultural group (Penderhughes, 1989). In the realm of language access,
empowering patients includes providing mechanisms (e.g., bilingual employees,

interpreters, translated materials and signage) in a system that enable their
navigation and inform them of their rights.
Culture and Ways of
Communicating About Health
Communication is both the most basic and the most powerful vehicle of
health care (Roter & Hall, 1997, page 206). The patient and provider relationship
is built through communication and the effective use of language. When barriers
exist, needs or the practical instructions that make cooperative endeavors possible
cannot be specified (Bolton, 1985). Language barriers can interfere with a
persons ability to accurately assess meanings, intent, emotions, and reactions.
Misunderstandings in any of these aspects of communication create challenges to
getting critical needs met.
If the provider lacks the language skills as well as an understanding of the
patients cultural perceptions about health, illness, and rules of conduct, it can
hinder the communication that could otherwise take place. Patients and providers
draw on many complex features in their lives and cultures to make sense of health
and disease (Brown & Corbett, 1995). Immigrants are typically seen by providers
of different cultural and class backgrounds. Each may hold a different view of the
world of medicine, the medical encounter, the terminology that is used, and how
they frame illnesses and symptoms (Kleinman, 1988; Ventres & Gordon, 1990).

Providers may not understand the implications that certain symptoms hold for
patients because the perception and interpretation of somatic feelings are
frequently defined by cultural idioms (Kleinman et al. 1988). Furthermore,
providers may make incorrect assumptions about the background of patients based
on their ethnicity. For example, it cannot be assumed that all Latinos have similar
perceptions about health and illness. Highly educated and affluent Latino
immigrants may have attitudes and beliefs about health care comparable with
people acculturated to the United States health care system. Latino immigrants
who are poor, have little or no formal education, and come from rural areas are
more likely to have a different view of health care (Haffiier, 1992). When
providers fail to consider sociocultural factors, they may resort to stereotyping,
which can affect their behavior and clinical decision-making (Betancourt et al.
Language combines with cultural styles of communication to influence the
effectiveness of the medical encounter (Erzinger, 1991). Although variations exist
among subgroups, many Latinos feel they should agree with physicians out of
politeness and respect, even when they really disagree or do not understand the
issues involved (Erzinger, 1991; Haffiier, 1992). Deferring to a physician may
occur due to underlying cultural attitudes of respeto (loosely translated as
respect) and personalismo formal friendliness. Even though the doctor is seen
as an authority, the patient simultaneously expects personal warmth. Some

Latinos may also expect simpatta, where the concern for others is expressed
through personal warmth and respect (Perez-Stable, 1987).
Maintaining simpatta may take precedence over meeting personal health
care needs. Deference to authority may lead to the patient not speaking up when
they dont understand a diagnosis or treatment or when they might prefer a
different procedure or method of care. A patients deference may be seen as a sign
of passivity by health care professionals. This creates a situation that compromises
informed consent if the health care professional begins to make decisions for the
In health care settings, language barriers can create a state of dependency
upon the person who holds the key to the entire clinical encounter (Putsch, 1985).
This person could be the provider, the interpreter, or another health care
professional. The patient-provider relationship has historically been dominated by
a paternalistic approach to patient care. In this approach, health care professionals
protect the interest of the patient because they have special medical knowledge
that the patient does not have. The patient, in turn, takes on a sick role making
him or her exempt from societal responsibilities and requiring their cooperation
with the providers orders (Parsons, 1951).
This type of approach in the provision of care is problematic even for
patients who speak English. A national Commonwealth Fund survey (Betancourt
et al. 2002) found that communication problems reported by English speakers

include: (a) their doctors did not listen to everything they said, (b) they did not
fully understand their doctor, and (c) they had questions during the visit but did not
ask them. These problems were magnified for Spanish speaking Latinos who were
surveyed. When language barriers exist, communication between providers and
patients tends to be concerned primarily with symptomology, to the exclusion of
feelings, causes, or patients questions (Rivadeneyra et al. 2000). A focus on the
dynamics of typical clinical interactions may illustrate why LEP patients who
experienced a medical encounter where an interpreter was not used, rate their
providers as less friendly and less respectful than do patients without language or
culture barriers (Baker et al. 1998).
Two critical approaches to quality health care need to be applied when
working with patients: (a) medical care and (b) psychosocial care. Medical care
requires clinical reasoning and observation of non-verbal cues, in addition to
diagnostic tests. Psychosocial care encompasses the beliefs, values, and behaviors
of the patient. While quality care utilizing more physiological and concrete forms
of assessment may be possible when language barriers exist, the initial assessment
leading to selection of the appropriate medical test should be based on the patients
description of their symptoms and the cultural context from which they are
speaking. Incorporating the psychosocial component of care is crucial in assessing
patient satisfaction with the medical care in relation to their cultural concepts of
disease and ultimately their compliance to the recommended treatment (National

Alliance for Hispanic Health, 2000). To provide quality psychosocial care, along
with the more objective medical care, providers must have a deeper understanding
of cultural nuances, including a better grasp of the language, to reveal the patients
true sentiments.
Language Barriers in Health Care
Language barriers can have unintended detrimental effects on the health
and well-being of patient populations with limited English proficiency. Mexican-
Americans average fewer physician visits per year than other ethnic groups in the
United States (Hough et al. 1987; Trevino et al. 1991). Whether this is due to
language barriers is uncertain. Studies have shown that among Spanish speaking
Latinos, language may be the most important factor related to the use of health
care (Suarez & Pulley, 1995), access to surgery and acute care (Andersen et al.
1986; Gany & De Bocanegra, 1996; Valdez et al. 1993), and preventive care
services (Quesada, 1976; Marks et al. 1987) like mammograms and cervical cancer
screenings (Woloshin et al. 1997) and well-child checks (Weinick & Krauss,
2000). Derose et al. (2000) found that poor English proficiency was as much a
barrier to Latinos seeking health care as was lack of health insurance. When
language and cultural barriers are present, patients receive less information about
therapeutic regimens, understand less of the medication instructions (Shapiro &
Salzter, 1981), are less likely to keep subsequent appointments, are more likely to

make emergency room visits (Manson, 1988), and are more likely to have under-
immunized children (Perez, 2000) than are patients who do not experience
language barriers.
The Ethics of Using Informal Communication Strategies
Enactment of Title VI ended the most blatant forms of health care
discrimination, but barriers still exist that prevent ethnic minorities from gaining
access to federally funded health and social services they are legally entitled to
receive (OCR, 2000). Lack of attention to reducing these barriers could
potentially have serious legal and ethical consequences for health care
organizations. Health care services should be provided in ways that allow
individuals to fully understand the nature and purpose of the service they receive.
However, economic constraints impact the ability to achieve this goal and
frequently require trade-offs involving access, cost, and quality of service (Chang
& Fortier, 1998). At times, these trade-offs become the norm and informal
practices are put into place that jeopardize the accuracy of the medical information
a patient receives. These informal practices include utilizing family members or
an untrained clinic employee to provide interpretation.
Many times responsibility for interpretation falls on the shoulders of any
bilingual person convenient to the scene such as employees, other patients, or
family members, persons not specifically trained to provide medical interpretation.

In many health care organizations, it is standard practice to rely on bilingual
employees or advise patients to bring someone with them to interpret during the
medical encounter (National Council on Interpretation in Health Care, 2001). The
use of a trusted family member or friend as an interpreter may seem ideal to some.
Unfortunately, this person is often unprepared to manage the complexities of
interpreting medical terminology and may have limited English proficiency
Having family members interpret can often compromise the confidentiality
of the patients encounter with a health care professional. Asking a family
member to deliver bad news to the patient for instance, is insensitive to the relative
acting as interpreter. It is easy to forget that the family member is also affected by
what is happening with the patient and that this person must assume a normal
family role when the interpreting duties are over (Haffher, 1992).
The person acting as interpreter is also in a position of power, although
they may have no awareness of this fact. If a family member is put in a position to
deliver information about complex health issues, it may be difficult for them to
remain entirely neutral. The interpreter is in a position to manipulate not only the
information exchange, but also the situation (Putsch, 1985). If, for example, an
adult child wanted to protect her parent from receiving bad news, she may not
fully disclose what the provider is saying. Another scenario where disclosure

could be jeopardized is when a patient is fearful of revealing signs or symptoms of
their condition in front of a family member, especially someone of the opposite
sex (Baker et al. 1998).
Many times the only qualified interpreter is a child of the patient.
Putting a child in this role has health implications as well as cultural ramifications
by compromising the mores of the family structure. In Latino cultures, the family
hierarchy is strict, with authority typically running from older to younger and from
male to female, with parents in control of the children and older adults in control
of their younger adult siblings. The head of the family is expected to make
decisions regarding any family member. The whole family looks to this person for
support and advice. By using a young family member as an interpreter, the
physician puts the child in control, with a much higher status than the child would
otherwise have. This essentially disrupts the familys social order (Haffher, 1992).
Using a bilingual employee not trained to interpret has limitations as well.
Many staff members live within the community they serve. These employees
bring their own unique views, emotions, and beliefs to the clinical setting and they
often know personal information about the patient before the medical encounter
begins. In these situations the patients privacy and their right to confidential
treatment is compromised. Asking a bilingual employee to interpret can also
create internal conflicts for the patient. They may not fully reveal their condition
due to lack of trust.

When bilingual employees serve as medical interpreters outside of their
regular responsibilities, a disruption in the organizational structure occurs that
affects quality of care. Employees who interpret are uncomfortably suspended
between doing their real work for their units and demands from the agency at
large (Putsch, 1985). Many times this role goes unrecognized by the organization
and creates animosity among employees and toward their employers.
Having bilingual employees does not always mean adequate medical
interpretation is being provided. Feeling hurried to return to their real jobs,
bilingual employees might paraphrase or not know the medical terminology in the
required language and thereby miss critical information during the patient
encounter. This could greatly affect a patients perceived knowledge of their
diagnoses and treatment (Baker et al. 1996), and health outcomes (National Health
Law Program, 1998).
The use of a trained medical interpreter improves encounters where the
provider and the patient do not speak the same language, especially if the
interpreter is from a similar culture as the patient, has developed a rapport with the
patient, and/or demonstrates a good understanding of the words and idioms used in
the culture. Weaver (1982) found that developing a bond of trust between the
provider, patient, and interpreter was crucial in eliciting information that could be
used to accurately diagnose and treat the patient.

The problem is that even when qualified medical interpreters are available,
they are not utilized to their fullest potential. Baker et al. (1996) found that
Spanish speaking patients in emergency units in Los Angeles County did not
receive interpreters when needed. Another study found that when both the
providers Spanish and the patients English are poor, an interpreter was not called
one-third of the time (Baker et al. 1998). When providers have limited Spanish
speaking ability, patients have limited English proficiency, and an interpreter is not
present, patients receive less preventive information or referrals from their
providers than English speaking patients and experience more misdiagnoses of
illnesses as a result of poor communication (Fadiman, 1997).
Informed consent and informed decision making are increasingly important
ethical issues in health care today. Ensuring true understanding between health
care professionals and patients who do not speak the same language is critical for
giving informed consent. When trade-offs become the norm, interpreters are not
used, and informal strategies for providing language access are implemented, this
impacts true informed consent.
Another issues that can impact understand and true informed consent is
literacy. Literacy levels among LEP patients compounds communication barriers
even further. According to the National Adult Literacy Survey, about one fourth
of Americans do not have the ability to read, write, and speak in English and
compute and solve problems at levels of proficiency necessary to function on the

job and in society (Kirsch et al. 1993). Health care professionals trying to
overcome the lack of verbal communication with written communication may
provide materials in the patients primary language. The problem with this
approach is that patients are frequently non-literate in their native language.
Williams et al. (1995) found that the prevalence of inadequate functional health
literacy among Spanish speaking patients in an emergency unit in California was
42%, based on their scores on the Spanish version of the Test of Functional Health
Literacy in Adults (TOFHLA-S). A GWMC literacy study found Spanish
speaking patients to be significantly more likely to have marginal or inadequate
literacy skills compared to English speaking patients (Lasater et al. 2003).
Language Access Policies
In the past, it was expected that providing an interpreter was the patients
responsibility (Chang & Fortier, 1998). Policies began shifting the responsibility
from the patient to the health care organization during the civil rights movement in
the 1960s. Since the passage of the Civil Rights Act of 1964, national, state, and
local organizations have spent millions of dollars and hundreds, if not thousands,
of person-hours proposing and lobbying for policies and regulations to improve
language access, and bring this issue to the forefront of health care policy.
Examples of federal policies affecting language access in addition to Title VI of
the Civil Rights Act are located in Table 2.1. As of 1995, at least 12 states and the

Table 2.1 Federal Policies Related to Language Access
Year Proposed By Area affected Regulation
1976 DOJ HHS funding recipients Translate forms
1985 HCFA Medicaid recipients If group 10% of health plan, translate forms in the groups language
1990 OMH&HRSA CHCs Disadvantaged Minority Health Improvement Act 1. $3 million/year to interpretive services 2. All services in the language of the recipient.
1992 DOJ All government services Americans with Disabilities Act 1. Provide interpreters
1998 HCFA Medicaid Balanced Budget Act 1. Translate forms 2. Provide interpreters
2001 Executive Order 13166 All government services 1. Provide interpreters 2. Translate forms
District of Columbia had passed legislation concerned with language access to
health care services. Due to lack of formal oversight, many of these legislative

efforts are primarily symbolic and have little impact on creating formalized
interpreter services (Fortier et al. 1998).
Private sector agencies have also put pressure on health care organizations
to develop language access policies. The Joint Commission on the Accreditation
of Healthcare Organizations (JCAHO) now requires hospitals to employ policies
that provide effective communication means for each patient served (JCAHO
2003). The JCAHO is an independent, not-for-profit organization that evaluates
and accredits over 19,000 health care organizations in the United States. Their
accreditation is required for Medicare and Medicaid funding. The JCAHO rules
state that organizations need to provide interpreters as necessary appropriate to
the age, understanding and language of the patient, and it offers a general
mandate patients deserve care, treatment and services that safeguard their
personal dignity and respect their culture, psychosocial, and spiritual values
(JCAHO, 2003).
Although JCAHO rules do not mention specifics about the order of
accessing services to facilitate language access, it does state generally that
organizations need to provide interpreters as necessary appropriate to the age,
understanding, and language of the patient and patients deserve care, treatment,
and services that safeguard their personal dignity and respect their culture,
psychosocial, and spiritual values (JCAHO, 2003). Note that the JCAHO rules

not only mention language, but also health care organizations meeting the needs of
the patient based on their individual culture.
The Health Plan Employers Data and Information Set (HEDIS) 3.0 is a set
of indicators utilized by health care organizations around the nation to inform them
about quality of care. The HEDIS now includes indicators of patient ethnicity and
primary language and the availability of linguistically appropriate clinical and
administrative services. By addressing language access issues through HEDIS
guidelines, the Health Care Finance Administration (HFCA) and the National
Committee for Quality Assurance are stating that language needs are just as
important as other components of quality care. To emphasize this point, HCFAs
national Quality Assessment and Performance Improvement goals for 2002
focused on clinical health care disparities and culturally and linguistically
appropriate services within the managed care industry (HCFA, 2002).
Additionally, the Health Resources and Services Administrations Bureau of
Primary Health Care, the oversight agency for Community Health Centers around
the nation, is putting additional emphasis on the provision of culturally and
linguistically appropriate services in health care.
The Cost of Language Access versus Language Barriers
The cost of providing language access is a frequently cited concern among
health care systems that fall under the OCR mandate. Some argue that enhanced

communication can have a positive impact on cost containment (Fortier, 1998);
others believe there are economic consequences of both providing services and not
providing services in a patients language. Very little empirical research has been
conducted on the costs of providing services and costs are difficult to quantify.
One survey of eight health care institutions in Seattle showed that the added
expense of working with LEP patients does affect health care budgets (Perkins et
al. 1998). Additionally, the Office of Management and Budget put the estimated
annual cost of interpretation services as high as $267.6 million, covering 66.1
million emergency room, inpatient, outpatients, and dental visits (National
Conference of State Legislatures, 2002).
Providers frequently state that encounters with LEP patients take longer. It
is uncertain whether time and efficiency are really affected when working with
these patients. In a time and motion study, Tocher et al. (1999) found no
significant difference in total time elapsed between encounters that required a
medical interpreter and those that did not require interpreter services. This study
did not assess the quality of the care provided. Providing culturally and
linguistically appropriate services may in fact have the potential to increase a
clinics efficiency (Anderson et al. 2003). The length of an encounter may
inversely correlate with the quality of the information exchanged between the
provider and the patient in that it serves as an index of the providers ability to

communicate and understand the patients health concerns and their willingness to
address these needs in the treatment plan (Weaver, 1982).
What is often not considered are the human and societal costs and that poor
language access to health care has ramifications on health outcomes (National
Council on Interpretation in Health Care, 2001). As mentioned previously, if
patients do not fully understand their diagnoses or treatment regimens, then there
is great potential for error that could create or intensify health problems.
Neglecting to ensure proper communication between patients and providers can
lead to inappropriate or unnecessary testing (Perkins et al. 1998), misdiagnosis,
and negative health outcomes (Fortier, 1998). More research is needed in these
areas to offset the arguments that providing language access only have financial
Community Health Centers
Around the time the Civil Rights Act of 1964 was passed, community and
migrant health centers (CHC) were authorized by the federal government to
increase the availability of primary and preventive health care services for low-
income people living in medically underserved areas. The majority (65%) of
patients seen at CHCs have annual incomes at or below the federal poverty level,
with little to no insurance (USGAO, 2000). Those with insurance typically have

Medicare or Medicaid. Many patients also face serious non-financial barriers to
health care (i.e., language, disabilities, and lack of transportation) and/or face
complex health and social problems (National Association of Community Health
Centers, 1995). CHCs also serve a disproportionate number of ethnic minorities,
who are primarily children and women of childbearing age. Almost one-third of
CHC patients are Latino. One in five of their patients need an interpreter to use
their services (USGAO, 2000).
Conveniently located in the communities they serve, one of the most
important characteristics of primary care at a CHC is accessibility.
Administratively, CHCs take into account the communities they serve by
providing non-traditional clinic hours, as well as on-site services at worksite or
migrant camp-based clinics. Most critically, CHCs provide cultural and linguistic
accessibility that transcends the elementary availability of interpreter services [at
other locations] (National Association of Community Health Centers, 1995).
Currently, there are over 600 community health centers nationwide that serve over
8.3 million people (USGAO, 2000). CHCs are especially created and funded to
provide culturally and linguistically appropriate services to medically underserved
communities. Having years of experience serving diverse communities creates a
setting ripe for conducting health disparities research.

The theory of Diffusion of Innovations provides the framework for this
study. Promulgated in the early 1960s by Everett M. Rogers, this theory has been
used in a wide array of disciplines in more nations than any in the field of
behavioral science research (Rogers & Scott, 1997). Diffusion is the process by
which an innovation is communicated through certain channels over time among
the members of a social system. Innovation is an idea, practice, or object that is
perceived as new by an individual or other unit of adoption (Rogers, 1995).
Essentially, diffusion is striving for a type of social change and the process by
which alterations occur in the structure and function of a social system.
Historically, Diffusion of Innovations has focused on individuals during the
diffusion process and factors that facilitate or impede the innovation-decision
process. Recently, the focus has shifted toward organizations and the interactive
nature of the knowledge exchange process (Anderson & Portnoy, 1989) and policy
(Pankratz et al. 2002).
The Civil Rights Act is an innovative policy written as an outgrowth of a
political and social movement to create social change. The rationale for using the
Diffusion of Innovations theory is that the law was trying to make a change from a

history of racial injustice and inequality to fair and equitable treatment of people
from different backgrounds with respect to public accommodations, jobs,
education, and health care. When considering Title VI from this perspective, one
begins to recognize the appropriateness of the Diffusion of Innovations theory for
providing a framework for exploring how language access policies are put into
practice within the social system of Great West Medical Center (GWMC).
This chapter will highlight the many facets of the theory. Attributes of
innovations that affect their adoption or rejection are discussed. Other components
such as time, communication channels, and social system are explained along with
the organizational processes needed to put innovations into place. The benefits of
utilizing anthropological methods in studying the Diffusion of Innovations are also
highlighted. Additionally, the limitation of the theory will be discussed in light of
the divisive nature of Title VI of the Civil Rights Act and the practices being
Attributes of Innovations
Studies have identified a set of characteristics, or attributes, that influence
why innovations are adopted or rejected by individuals. The primary attributes
developed by Rogers and others are listed in Table 3.1. These attributes provide
objective guidelines that align with specific Office for Civil Rights (OCR)

recommendations for understanding why a GWMC innovation (e.g., medical
interpreter, language line, or bilingual employees) was or was not implemented.
Table 3.1
Attributes of the Diffusion of Innovations Theoretical
Framework as They Relate to Language Access_______
Attribute Consideration
Relative advantage Is the practice better than what was in place before?
Compatibility Does the practice fit with the organizational culture or the clinical encounter?
Complexity Is the practice easy to implement?
Trialability Can the practice be subjected to a trial run?
Observability Are the results of the practice observable and easy to measure?
Impact of social relations Is the practice disruptive to staff or patients?
Time required Can the practice be implemented with minimal investment of time?
Cost Can the practice be implemented without increasing costs?
These attributes were also used as a priori codes during analysis.
1. Relative Advantage: The degree to which an innovation is perceived as

better than the idea it supersedes. This can be measured in economic terms, social
prestige, convenience, and satisfaction levels. The key is whether an individual
perceives the innovation as advantageous.
2. Compatibility: The degree to which an innovation is perceived as
consistent with the existing values, past experiences, and needs of potential
adopters. An idea that is not compatible with the norms and values of a system
will not be adopted as rapidly as an innovation that is compatible.
3. Complexity: The degree to which an innovation is perceived as
relatively difficult to understand and use. Ideas that are simpler to understand will
be adopted more rapidly than innovations that require the adopter to learn
something new or to develop new skills.
4. Trialability: The degree to which an innovation may be experimented
with on a limited basis. Ideas that can be used on a trial basis are generally
adopted more quickly than those that are not flexible.
5. Observability: The degree to which the results of an innovation are
visible to others. The easer it is to see the results of an innovation, the more likely
the innovation will be adopted.
6. Impact on social relations: The degree to which the results of an
innovation impact social relations. The lower the negative impact on relationships,
the more likely the innovation will be adopted.

7. Time required: The degree to which the results of an innovation affect
investment of time. An innovation that requires less time to implement is more
likely to be adopted.
8. Cost: The degree to which results of the innovation affect costs. The
lower the costs of implementing the innovation, the more rapidly it will be
Communication Channels
One of the most important elements in the diffusion of new ideas is the
channel of communication through which the innovation travels. A
communication channel is the means by which messages get from one person to
the other. Research has demonstrated that mass communication is an effective
channel for creating knowledge of innovations. In contrast, interpersonal channels
are more effective in forming or changing attitudes toward a new idea. These
interpersonal channels influence decisions to adopt or reject new practices (Rogers
& Scott, 1997). While diffusion usually takes place through informal systems,
organizations must deliberately create diffusion systems or communication
channels to bridge the gap between policies and practices and the potential users of
the innovations. This is especially true when policy and practice innovations stem
from governmental legislation. The health care organization must diffuse the
policies and practices in such a way that it will be a good fit within the

organizational culture. In the case of language access, the diffusion process has
been limited.
Another main element in the diffusion of new ideas is time. Time is a
factor in three ways: (a) through the innovation-decision process, (b) through the
innovativeness of the individual or organization, called a change agent, and (c)
through the rate of adoption.
Innovation Decisions
The innovation-decision process is a mental procedure through which an
individual (or other decision-maker) must complete. First, the individual must
have knowledge of an innovation (in this case language access innovations like
medical interpreters or language line services). Second, the decision-maker must
form an attitude about the innovation in order to make a decision to adopt or reject
the innovation, implement the new idea, and confirm the decision (Rogers & Scott,
1997). Potential decisions are as follows:
1. Optional innovation decisions: Choices to adopt or reject an innovation
made by an individual independent of the decisions by other members of a system,
2. Collective innovation decisions: Choices to adopt or reject an innovation
made by consensus among the members of the system,

3. Authority innovation decisions: Choices to adopt or reject an innovation
made by the relatively few individuals in a system who possess power, status, or
technical expertise, or
4. Contingent innovation decisions: These types of decisions to adopt or
reject an innovation can only be made after a prior decision has been made to
implement an innovation. For example, a provider could not use the language line
until GWMC made the decision to contract with the service.
All four of these innovation decisions are found in the GWMC system in
relation to language access. Title VI of the Civil Rights Act is an authority
innovation decision made by the federal government. A law was passed and
penalties can be imposed if GWMC is found to be out of compliance.
A collective decision was made by GWMC administrators and providers to
implement policies and practices based on the OCR Policy Guidance with the
intent of increasing meaningful language access for LEP patients. Despite these
intentions, optional innovation decisions and contingent innovation decisions
made by departments (e g., pharmacy) or individuals independent of the GWMC
policies also affect implementation of the innovations.

Innovativeness of an Individual or Unit of Adoption
The second way in which time is involved in the diffusion or the adoption
of an innovation is related to the innovativeness of an individual or organization,
called a change agent. There are five categories of change agents:
1. Innovators: Individuals or organizations who launch new ideas by
bringing in the innovation from the outside. The innovator change agent plays a
gate-keeping role in the flow of new ideas into a system.
2. Early Adopters: Individuals who are more integrated into the local
system and serve as role models and opinion leaders for other members of a social
system who may be potential adopters.
3. Early Majority: Individuals or organizations who adopt new ideas just
before the average member of a system. These individuals or organizations
provide interconnectedness in the systems interpersonal networks by willingly
adopting innovations, but they do not lead the charge.
4. Late Majority: Individuals or organizations who adopt new ideas just
after the average member of a system, usually as a result of increasing network
pressures from peers. The systems norms must strongly favor the innovation to
motivate adoption among those individuals in the late majority.
5. Laggards: Individuals or organizations who are social isolates. They
make their decisions based on what has been done previously and are suspicious of
innovations and change.

The Rate of Adoption
The third way in which time is involved in diffusion is through rate of
adoption, or the speed with which members of the social system adopt innovations.
Social System
The fourth and final element in the diffusion of new ideas is the social
system. Rogers (1995) defines a social system as a set of inter-related units (e.g.,
individuals, groups, and organizations) engaged in joint problem-solving to
accomplish a common goal. Changing behavior patterns or norms and the
opinions of change agents affects the social system. In the case of GWMC,
opinion leaders advocating language access policies and practices are the
administrators in Community Health Services and Interpreter Services. The
change agents are the health care professionals who implement innovations in a
system where set patterns of behaviors may influence their rejection or adoption.
Diffusion of Innovations is often used in the context of health promotion
programs. Because policies are used as one of a variety of methods to disseminate
efforts to change health behaviors, the theory can transfer to the policy realm (Hill
& Borland, 1989). Other research has already demonstrated that the theory is
useful in clinical settings (Bodenheimer, 2003; Helitzer et al. 2003; Strasberg &
Ludbrook, 2003).

In the case of language access, one finds a disconcerting lack of
compliance in health and social service agencies given that Title VI of the Civil
Rights Act was developed over 35 years ago. Until recently, the OCR has not
effectively diffused information about language access in relation to this policy
directed toward HHS-funded agencies (National Council of Interpreters in Health
Care, 1999). The assumption is often made that the passage of legislation or the
adoption of an innovation automatically results in implementation. Evidence from
other studies demonstrates that initial attempts at incorporating changes into daily
life do not usually lead to sustained behavior change (Anderson & Portnoy, 1989;
Stumpf et al. 2002). This lack of implementation or sustainability exists currently
in our health care system. A recent editorial admonishes the health care industry,
which is rich in evidence-based innovations, for not implementing and widely
disseminating their science successes and best practices (Berwick, 2003).
Identifying how an innovation is diffused and adopted, and also how it succeeds or
fails in achieving a sustainable and meaningful impact on the organization and the
population it serves, should be assessed as well.
Most diffusion research has been spent studying the differences in adopter
categories in innovativeness (i.e., early adopters to laggards). Little effort has
been devoted to analyzing innovation differences. Rogers (1995) states that this
latter type of research is of great value in predicting peoples reactions to an
innovation. This study concentrates on exploring peoples reactions to the

attributes (i.e., what is helpful or what is inadequate) of language access policies
and practices and how health care professionals perspectives and experiences
affect their ultimate adoption of these innovations. By changing the way an
innovation is named and positioned in the clinical setting, reactions of health care
professionals can be modified.
Innovations in Organizations
This study also includes a broader perspective by examining how the
organization facilitates or impedes the implementation of language access policies
and practices. In this section, the innovation process is discussed in relation to the
complexity of diffusion in organizations. Organizations are systems of individuals
who work together to achieve common goals through a hierarchy of ranks and a
division of labor (Rogers, 1995). As can be seen in the findings of this study, once
a decision to adopt has been made in an organization, implementation does not
always directly follow. It is assumed that organizational variables act on
innovation behavior over and above individual members of the organization.
There are certain processes that take place within an organization during
the implementation of an innovation. Table 3.2 highlights the stages of these
processes. Later stages cannot be undertaken until earlier stages have been

Table 3.2
Stages of the Innovation Process
Stages Explanation
Agenda-setting the problem that prompts the need for an innovation is identified
Matching an innovation that can potentially solve the problem is identified
Redefining/ Restructuring an innovation is modified to fit the organizations structure
Clarifying the innovation becomes more understandable to the providers and staff
Routinizing the innovation is incorporated into routine areas in the practice
1. Agenda-setting: This occurs when an organizational problem or
performance gap creates a perceived need for an innovation. During this stage,
organizations identify and prioritize needs and search the environment for useful
solutions. In terms of language access, the agenda was set for GWMC due to the
OCR mandate.
2. Matching: This is when a problem is connected to an innovation.
During this stage, feasibility testing is conducted to determine if the innovation
will solve the organizations problem.
3. Redefining/Restructuring: Part of implementation, this stage is when

the innovation is reinvented to accommodate the organizations needs and
structure and when the organizations structure is modified to fit the innovation.
An example of how the organization might change is when a new unit is created to
take on the responsibility and oversight of the innovation. In the case of GWMC,
an existing unit, the Department of Social Work, took on the responsibilities of
Interpreter Services.
4. Clarifying: This occurs when innovations are more prevalent within
an organization. As such, the new idea becomes clearer to the organizations
members. Implementing an innovation too rapidly could lead to negative
5. Routinizing: When an innovation has been incorporated into regular
organizational activities and it loses its separate identity, it has been routinized.
The Importance of Language Access Innovation Research
Language is an integral part of a culture. Because language access policies
and practices are changing the health care culture, health care systems should
explore the perceptions and experiences of its health care professionals and
patients with regard to these innovations. To date, some language access practices
(e.g., language line services) in the GWMC system have been examined via pilot
studies. Conducting studies like this using baseline and follow-up data collection

as others have done in clinical settings (Bach, 1989) may help GWMC elicit how
and if policies and practices are being adopted within the clinics.
Using anthropological methods can also be beneficial. Anthropological
studies have shown that planners and officials in charge of the development of
programs sometimes fail to fully account for the cultural values of the potential
adopters (Justice, 1986). In this study, the Office for Civil Rights has created
legislation with the good intention of assisting peoples from different cultures.
How these mandates are then integrated into a health care organizations sub-
culture remains uncertain. The National Alliance for Hispanic Health (2000, pg.
22) seems to acknowledge this when it states.
The concept of linguistic accommodation in clinical human service
settings, even without the impetus of law, is easy to support, as a
common sense approach, smart business, and ethically responsible.
Its the development of practical means for realizing this
accommodation that poses a great challenge to health care
When the culture of patients or the health care system is not considered,
programs may fail, not realize their fullest potential, or lead to unanticipated
consequences. The methodology utilized in this study, interviews and observation,
lends itself to exploring the culture of the GWMC and the desirable and
undesirable consequences of language access policies and practices.
The methods of interviews and participant observation can lead to a better
understanding of a persons worldview (Larkey et al, 2001). By examining the

GWMC health care professionals perspectives and experiences about language
access through the lens of the theory of Diffusion of Innovations, investigators
begin the process of understanding the emic, or within culture, interpretations
that are relevant to how practices and policies are being implemented. Learning
about the insiders view can help GWMC administrators understand which
innovations are most appropriate for the organizational structure and best
accommodate the patients culture.
Critical Medical Anthropology: The Power
and Politics of Language Access
Although the theory of Diffusion of Innovations was helpful in providing
an objective framework from which to work during the course of this study, it did
have limitations in that it is reductionistic in its approach. While the theory
permits the examination of consequences from a cultural perspective, it does not
allow much beyond this assessment or account for the complexities of human
interactions. The lens of critical medical anthropology provides an important
theoretical and practice perspective to understand and respond to issues and
problems of asymmetry of power and discrimination beyond the Diffusion of
Innovations framework. It challenges us to examine the interactions between
macro-level and micro-level issues. Macro-level issues include the political
economy of health from competition to monopolistic capitalism, the national level

of political and class structure, the institutional level of health care systems, and
the community level of folk beliefs and actions. Micro-level issues are the
patients illness experiences, behaviors, human physiology, and environmental
factors (Singer, 1998; Waitzkin, 1991). Although not perfectly dichotomous
(Pappas, 1990) when considering the complex features of our health care system, it
does provide a starting point from which to view issues related to language access.
Integrally connected to how federal policies, health care systems, and
health care professionals relate to patients, language access directly affects those
who often lack power and a voice within society. Hence, in the context of this
study, it is important to consider the historical and current context in which LEP
patients live, how the lack of power within these populations plays out in patient-
provider dyads, and ultimately how meaningful language access in health care can
be achieved.
A political economic perspective provides a framework from which to
consider how macro and micro level issues play upon one another. Economics
influence health care professionals behavior during medical encounters (Waitzkin,
1991). Studies have documented how economic capital is concentrated among
for-profit corporations thus undercutting other health services (Baer, 1989),
governments role in protecting this capitalist system and the interests of the class
structure in health care systems through policies; and how these ideologies play
themselves out in patient-provder interactions (Waitzin, 1989).

A Case Study
Stake (1998) asserts that a case study is not a method, but an object to be
studied, a bounded system with working parts and patterned behavior. Spending
time on-site in personal contact with the activities and operations of the case, and
reflecting and revising the meanings of what is happening characterize qualitative
case studies.
This study explored how a language access policy mandated at the federal
level was put into practice by a health care organization at the local level. Four
community health centers (CHC) and one acute care center affiliated with an
organization called Great West Medical Center (GWMC) participated.
Data describe the perspectives and experiences of administrators, health
care professionals, and LEP patients. Data collection methods were semi-
structured interviews and participant observation. These methods were used to
build upon information found in previous studies in the GWMC system
(LARASA, 2002; Lee et al. 2002; Burbano OLeary et al. 2002).

Key Informants
Key informant interviews were initially conducted with Community Health
Services (CHS) and Interpreter Services administrators to inform the study design.
I met with these GWMC representatives periodically throughout the study to
answer questions, clarify issues that arose during data collection, and gather a
system perspective about language access policies and practices.
Once the study began, team leaders and practice managers in the
participating clinics were also purposefully selected to be key informants. The
individuals in these roles were providers and nurses respectively. They all
maintained clinical roles in addition to their administrative duties. Preliminary
interviews were conducted with these key informants to learn how their clinic fit
within the GWMC system and more specifically about the clinics approach to
implementing language access policies. Informal meetings took place throughout
the study with these individuals.
Rationale for the Research Site
The GWMC was selected for a variety of reasons:
1. Community Health Services administrators and a GWMC physician who
were familiar with my work facilitated entree.
2. GWMC is a public health facility that falls under the jurisdiction of the
Office for Civil Rights (OCR) mandates because it received federal funds.

3. Public health facilities are more likely to provide care to ethnically diverse
patient population and LEP individuals.
4. GWMC collects information about the language preference of their
patients. Not all health care systems collect this type of data. Collecting
this type of information indicates that GWMC is aware of the importance
of language access and creating a more culturally competent health care
5. GWMC is interested in an in-depth exploration of what is being done in the
clinics after practices have been adopted in response to the OCRs 2000
Policy Guidance.
6. GWMC has a long history of interest in providing new and different
services to residents of the city and county. They seek improvements in
patient care by supporting a robust program of research throughout the
facility and the public health unit. This speaks to the organizations ability
to adopt new practices and its emphasis on innovation.
7. Over 35 years ago, the federal government funded GWMC community
health centers to provide culturally and linguistically appropriate care to
underserved populations. Ideally, the clinics of GWMC, should have a
good system in place for serving LEP patients from which we can learn.

Gaining Entree
In February 2001,1 met with GWMC administrators in the Community
Health Services division to discuss conducting this research study. Before the
meeting, numerous people had warned me it would be difficult to find a health
care organization that would permit me to examine such a politically sensitive and
potentially divisive issue due to the ramifications of penalization by the Office for
Civil Rights. However, the four administrators with whom I met quickly agreed to
allow me to conduct the study. Such rapid agreement may not have been so
forthcoming in an organization that was not open to innovation and was already
putting so many new practices into place.
The administrators enthusiasm for the study, they said, was a result of
their own curiosity about which practices are working and why. Other reasons for
their enthusiasm included: (a) being able to determine why recent data from an
internal GWMC pilot study demonstrated low utilization of the language line in a
community health center; (b) having someone come into a financially strapped
system free of charge to conduct this type of in-depth research allowing the staff to
focus more on program development efforts, and (c) creating a benefit to the
community health centers.
The director of nursing for Community Health Services arranged the initial
meetings with the CHS administrators. I was acquainted with the director of
nursing though our involvement in a scientific and community partnership for

improving health outcomes for Latinos. This familiarity improved the ability to
gain access to the GWMC system and its affiliated clinics throughout the course of
the study.
The administrators and a physician mentor required by GWMC for any
outside investigator conducting research in the system, were integral in helping me
gain entree. They made recommendations and provided insights on: (a) how to
proceed and with whom I should speak before the study began, (b) which clinics
should participate in the study, (c) the inner workings of GWMC administration
and the practices being put into place within the CHCs, and (d) questions
generated by interviews and observations.
In collaboration with administrators, four clinics were tentatively
determined to be a good fit for the study. Their recommendation included two
clinics with a history of serving LEP Spanish speaking patients and two clinics
transitioning into serving more Spanish-speakers. Before approaching these
clinics, administrators thought it would be wise to announce the study to all
clinics to determine if others might be interested in participating.
After both a Human Subjects Review Committee and an Institution Review
Board granted permission to begin the research, I presented the study proposal at a
CHS leadership meeting on December 6, 2001. The CHS director of nursing
facilitated including the study as an item on the meeting agenda. CHS

administrators, team leaders, and practice managers from all the clinics affiliated
with GWMC attended the meeting.
The 10-minute presentation highlighted in Appendix D included a brief
study overview, my background in community health and interest in conducting
this type of research, and the potential benefits for the CHCs. The study topic
seemed to resonate with meeting attendees as they nodded affirmatively
throughout the presentation. Immediately after the meeting, a representative of the
Center for Acute Pediatric Care, a Community Health Services administrator, and
a clinic director approached me expressing interest in participating. Within two
days, two adult medicine practice managers called for more information about the
Five clinics were ultimately chosen to join the study, four community
health centers and one acute care clinic. The original study design had not
included an acute care clinic. However, the Center for Acute Pediatric Care was
integrated into the study because it provided a way to compare language access
across acute care and primary care clinics. Data collection began January 2002.
Before beginning data collection in each clinic, a meeting was held with
each clinic team leader and practice manager respectively to explain the study and
solicit their interest. After they agreed, presentations were given at various
meetings to inform the entire clinic staff of the study and seek their input. Table
4.1 lists the presentations and when they were conducted.

Table 4.1 Clinic Presentations to Describe Study
Presentations Date
Wesley Clinic adult medicine unit January 25, 2002
Hamilton Clinic February 7, 2002
Center for Acute Pediatric Care February 8, 2002
GWMC Multicultural Task Force February 15, 2002
Wesley Clinic pediatric unit February 21, 2002
Parker Clinic March 6, 2002
Eagleton Clinic adult medicine unit March 19, 2002
Eagleton Clinic pediatric unit August 7, 2002
These initial meetings had two positive outcomes: (a) it introduced the
study to the clinic staff, and (b) it provided an informal way to begin the process of
exploring perspectives, problems, and experiences related to working with LEP
patients. I held these meetings to ensure the study did not appear covert in its
intention. The outcome of these initial discussions helped to inform the type of
issues explored during the course of the study.

Being an Employee of GWMC
Part of what precipitated peoples willingness to speak openly about
language access issues was that I was an employee of GWMC. I began working
part-time (about 20 hours a week) as a research assistant in three clinics four
months before this study began. As an employee and a researcher, I was not only
an observer of clinic activities, but also a participant.
Historically, there has been a debate about the method of participant
observation. Where some have argued for a more detached, objective role for
researchers, others have urged the importance of seeking to understand the social
world and perspectives of members themselves via direct naturalistic interaction.
It is only then that researchers can come to fully understand the mundane details
and pivotal concerns of their subjects lives (Adler & Adler, 1987).
Being a member of the organization where I was conducting research put
me in a unique position. Two of the clinics where I had been working, agreed to
participate in this study. In these clinics, I was an insider. My presence was
justified because I had already been participating in some clinic activities as an
employee. I worked closely with a doctor, wore a badge, worked independently
with patients, and interacted with the staff. Trust and rapport had been developed
before beginning the study. In this setting, I was a participant-as-observer. This
type of role is overt, typically involving brief and highly formalized interactions.

But, it involves greater contact and intimacy between the researcher and subjects
(Adler & Adler, 1987).
In the other three clinics, I was an insider and an outsider and a complete
observer. It was obvious that I worked with GWMC because I wore a badge and
attended staff meetings. Because of my presence in the clinic over time, there was
face recognition, and I was permitted in areas of the clinic only for employees, but
I did not work with the staff or patients in these clinics on a daily basis. I did not
attempt to establish enduring relationships with the employees. Although I did
develop rapport with staff during the course of the study, my role was as an overt
researcher; someone who came to the clinic periodically to observe, conduct
interviews, and ask a lot of questions.
Working as a research assistant before formal approval of the study, I was
able to initially enter GWMC as a passive participant, observing patient-staff
interactions from a peripheral vantage point. After getting a sense of the flow of
the clinic and formal approval to conduct the study, I was able to shift my role and
increase my involvement in other areas of the clinic. In this broader role, I was
able to learn more about and observe the roles of front desk clerks, nurses, medical
assistants, and medical interpreters. First, data were gathered in the clinics where
was working in as a research assistant, and then I progressed to the additional three
clinics. In the clinics where I was more of an outsider, interactions were typically
more formal and information seeking.

At times, although rare, other staff members asked me to take on the
temporary role of interpreter. In almost all cases, I would refuse unless the patient
was present when the request was made or unless it was related to my job as a
research assistant. I felt if I accepted this role of interpreter, it defeated the
purpose of this research. The request was made so rarely I never got the
impression that my declining to interpret affected the rapport I had with staff.
Overall, the employees at GWMC were very welcoming and open to my
presence. I was honest about what I was doing. I was an employee working at
GWMC, but I was also a student working on my own study. Throughout the
course of data collection, employees expressed interest in the topic area and were
willing to talk openly and at length with me about their experiences working with
LEP patients.
Rational for the Focus on Latinos
Providing health care services to LEP Spanish speaking Latinos was the
focus of this study for the following reasons:
1. Latinos are the largest ethnic group in the United States;
2. Twenty-one percent of the population in the area served by GWMC
speaks Spanish at home, with about 12% (62,690) stating they speak
English less than Very well (United States Census, 2000);

3. Latinos are the largest ethnic group served by GWMC. In 2002,
Spanish speaking patients served by the participating clinics ranged
from 16% to 92% of the respective clinics patient population; and
4. It is my second language.
Although the federal government uses the term Hispanic, the term
Latino was chosen for this study. This term is being used to aggregately
represent all people living in United States whose origin can be traced to the
Spanish speaking regions of Latin America, including the Caribbean, Mexico,
Central America, and South America. Latino is a more inclusive term that does
not de-emphasize the history of Latin America and the crucial roles of indigenous
Indian cultures and African slaves (Flores et al. 1998). The term Hispanic
places narrow and undue emphasis on the European influence of Spanish
colonialism (Aguirre-Molina & Molina, 1994).
Description of the Study Design
This study is ethnographic in its emphasis. Ethnography means learning
from, rather than studying, people (Spradley, 1979). According to Atkinson &
Hammersley (1998), ethnographic research:
Explores a particular social phenomena, rather than testing hypotheses;
Involves unstructured data rather than pre-set data analytic categories;
Focuses on a small number of cases;
Involves explicit interpretation of the meanings and function of human

Presents findings as descriptions and explanations with minimal
quantitative analysis.
This study fit these criteria by exploring language access policies and practices in
clinics and how they affected the everyday reality of LEP patients and health care
professionals. It included five clinics within a larger health care institution. The
aim of the study was to understand the perceptions and experiences related to
language access policies and practices by relying on key informant, informal, and
semi-structured interviews, and participant observation. Analysis involved
interpretation of meanings related to language access practices and how they affect
provider, nurse, support staff, and patient roles. This study was not intended to
investigate all observable aspects of the clinic culture or subculture. This study is
meant to be problem focused, as is the emphasis in most recent anthropological
studies (Justice, 1986; Valdes, 1996).
Participant Observation
The aim of participant observation in primary care research is to generate
practical and theoretical truths about human life grounded in the realities of daily
existence (Bogdewic, 1992, p. 46). In this study, periodic observations were
conducted to gain familiarity with provider, nursing staff, and support staff
interactions with LEP patients in the context of the outpatient visit. Observations
provided brief snapshots of how cultural and language barriers were overcome,

what language access practices were implemented, and how implementing
practices affected employee roles and the flow of the clinic. Observations were
conducted during varying days and times throughout the facility (e.g., waiting
areas, triage, pharmacy, and patient intake). Though observations were initially
broad to capture patient flow and organization of the clinic, over the course of the
study, observations were more focused and narrowed as specific issues and themes
emerged during analysis of the data.
Although rare, periodic observations took place during patient exams. On
occasion when observing providers, medical interpreters, or medical assistant, I
was allowed into the examination room. Before the medical encounter proceeded,
I was introduced and a brief description of my role was given to the patient (e.g.,
This women is learning about my role as a medical assistant) and then the
patient was asked if it was all right for me to observe. After verbal consent was
gained, the encounter would continue. Generally, if time permitted a brief
informal interview would be conducted with the health care professional and/or the
patient after the observed encounter to clarify aspects of the communication that
occurred or issues related to language access practices implemented.
Approximately 40 hours of observation time were spent in each clinic over
the course of the study period. All fieldnotes from observations were summarized
and transcribed each evening.

Semi-Structured Interviews
The rationale for choosing interviews over other types of data collection
methods (i.e., focus groups) was to facilitate a process of discovery that focused on
the individuals experiences working with, or being, a patient in the clinic. Health
care professionals and patients often tell stories about their clinic experiences. The
interviews were a means to gather critical incidents by which to learn about the
individuals experiences. The critical incident technique (CIT) guided the
development of the interview guides found in Appendices F and G.
In use for over 50 years, the CIT was initially used to study pilot
experiences and errors after World War II (Flanagan, 1954) and has since been
used in studies in the health care sector (Allery et al. 1997; Bendtsen et al. 1999;
D Alessandro et al. 1998; Norman et al. 1991; Orbe & King, 2000; Rosenal,
1995). The CIT is a method for evaluating systems in functioning work
environments. It is defined as a set of practices for using factual accounts of
events in such a way as to facilitate their usefulness in solving practical problems
and developing solutions. The term critical implies a crucial role in the system
behavior and not whether the event was an emergency, or a matter of life or death,
which may be the case in health care.
The CIT can be applied to any observable human activity (Flanagan, 1954).
A clinical encounter with a LEP patient would qualify as this type of activity.

People can reflect on their past experiences in a particular area and then answer
questions about the remembered event (Rosenal, 1995).
Before beginning interviews, the reason for the study was briefly reviewed
and informed consent gained. Consent forms can be found in Appendix E.
Interviews with health care professionals took place in a quiet location in the
clinic, usually an office or empty examination room, and were audiotaped. Patient
interviews took place in waiting areas. Informal hallway interviews also took
place to ask questions or clarify issues.
For patients, a 22-question guide and check list was adapted from the
original interview guide to create a version that would be appropriate for use
during waiting room interviews that were not audio taped. The guide was updated
as needed to elicit additional information from patients. For example, when the
issue of discrimination emerged from patient interviews, the guide was expanded
to include questions related to this issue.
Changes in the Study Design
Changes were made in the initial study design due to logistical problems
related to conducting interviews in busy clinic environments. The length of
interviews for health care professionals changed early in the study. Initially, the
study design included 30-minute interviews. Pilot interviews indicated that
providers would be more likely to participate if the interview was shorter. The

final interview guide was cut to 15 minutes and covered three key questions. The
interviewees enthusiasm and the time they had available ultimately determined
the length of the interview. This resulted in interviews ranging from 15 minutes to
one hour.
The location of patient interviews and hence the patient interview guide
also changed at the beginning of the study. Patients were going to be interviewed
in a private confidential space like an office or examination room. It became
evident from a logistical perspective that taking patients out of the queue to
conduct interviews would lengthen their clinic visit and greatly inconvenience
them. Though not optimal from a research or cultural perspective, brief interviews
were conducted with patients while they were in the waiting area.
As the study progressed, the number of study participants increased in both
health care professional and patient categories. The original study design
proposed conducting a minimum of 10 interviews within each category in each
clinic. Soon after entering the field, it became evident that 10 health care
professional interviews would be insufficient due to the size of the clinics and the
diversity of staff roles. Key informants also shared that in their eyes interviewing
only 10 patients in each clinic would not be a substantial enough number since
some clinics have 100 patients a day scheduled for appointments. The number of
patient interviews was increased to 20 in each clinic.

Study Participants
According to Crabtree and Miller (1992), in qualitative inquiry, sampling
should increase the range of data explored to uncover multiple realities. Hence, a
maximum variation sampling technique was used to select those interviewed for
this study. This form of sampling seeks to obtain the broadest range of
information and perspectives on the subject of study. To be eligible (See Table
4.2) for the study, patients had to be 18 years of age or older, speak Spanish with
limited English proficiency, a patient at the clinic, and agree to the interview.
Employees had to be 18 years of age or older and agree to the interview to be
Table 4.2 Eligibility Requirements
Requirement LEP Patients Health Care Professionals
18 years or older V
Agrees to interview / V
Speaks Spanish S
Receiving care at clinic V
Employee of GWMC /

Health Care Professionals. Both bilingual (Spanish/English) and
monolingual (English) providers1, nursing staff2, and support staff3 were identified
from multiple levels within the GWMC system. Employees were randomly
approached to determine their interest in being interviewed. If they expressed
interest, an interview was scheduled. Before the interview began the study was
briefly explained. Once their consent was granted and the informed consent form
was signed and the interview began. These interviews were audiotaped and later
In addition to interviewing clinic staff, Community Health Services (CHS)
administrators, and team leaders and practice managers from all five participating
clinic were purposefully selected for interviews to gain insights about language
access policies and practices from an administrative as well as a clinical
perspective. CHS administrators were interviewed because they make decisions to
adopt language access policies and practices for GWMC based on OCR
recommendations. Team leaders and practice managers from adult medicine and
pediatric units were interviewed because they make decisions related to implement
GWMCs language access policy and practices within their respective clinics.
Additionally, these administrators have knowledge about how the clinic functions
in the larger structure of the organization in addition to interacting with patients.
1 medical doctors, physician assistants, nurse practitioners, psychologists, and doctors of pharmacy.
2 registered nurses and licensed practical nurses
3 medical assistants, front desk clerics, medical interpreters