Improving language awareness in mental health care by engaging clinicians of language diverse patients

Background: Despite the diverse linguistic profiles of patients at inner city hospitals, language barrier between patients and clinical staff remains neglected. Reasons may include lack of awareness of language barrier by clinicians and silencing of barriers by organizational practices and management priorities. From prior research, inpatient psychiatry nurses and medical students are least likely to seek the help of interpreters when faced with patients that don’t speak English or French. Reasons for these practice patterns are unknown.

Objectives: Developing previous work, this study aims to clarify the quality of language barriers in clinical settings, focusing especially, but not uniquely, on the work of nurses and medical students, to (1) document clinician awareness of language barriers in their patients; (2) explore how awareness of language barriers can be enhanced professionally and institutionally; (3) evaluate the discourses reinforcing language barrier in clinical practice; and (4) assess whether promoting awareness of language barrier results in a measurable increase in documentation of language dynamics in patient charts and a corresponding increase in clinician satisfaction working with language diverse patients in clinical mental health settings.

Hypotheses: We hypothesize that after focus groups on language barrier over one year on psychiatric services, measurements at Time 1 compared to Time 2 will show (1) a statistically significant increase of clinician awareness of language barriers as measured by mentions of language issues in patient charts and (2) greater clinical satisfaction working with language diverse patients.

Research Methodology and Study Population: The study is divided into two phases, each of one-year duration. Phase 1 will consist of Time 1 ratings during the first year of mentions of language issues in 250 hospital charts of patients with diverse mother languages. A baseline clinician satisfaction survey of working with language diverse patients will be administered to 50 clinicians. After these ratings have been completed, a series of focus groups will be conducted in the last six months of year 1 with clinicians and hospital managers to explore experiences, perspectives and suggestions to improve clinical communication. Phase 2 will consist of follow up focus groups during the first six months of the second year to investigate whether clinician awareness of language barriers has affected individual and team practice i.e. to determine if any change has taken place. After the focus groups are complete, Time 2 ratings of mentions of language issues in 250 patient charts will be conducted, and a follow up clinician satisfaction survey of the same 50 clinicians will be administered, both as in Phase 1.

Data Analysis: Descriptive statistics will be calculated for each study variable. Measures that are scored dimensionally (i.e., clinician satisfaction ratings) will be assessed using Analysis of Variance (ANOVA). Measures that are scored categorically (i.e., language mentioned in chart yes/no) will be assessed using standard Chi-Square tests. Where power considerations allow, analyses will control for confounders that show influence on the pattern of results. Potential confounders include clinician type, clinician experience (years), language ability of patients and clinicians, and duration of time of patients in Québec. Focus groups will be audiotaped and transcribed, then analyzed using the qualitative software MAXQDA for constant emerging themes. This will provide a comprehensive understanding of the construct of language awareness and its associated elements in clinical mental health settings.

Relevance: Linguistic diversity is a fact in clinical care settings. This study will help to bridge the gap between patients who are linguistically diverse and their clinicians’ lack of awareness of linguistic diversity and how it may compromise quality of care.

Clinical Measurement of Verbal Language Proficiency in Patients Referred to a Cultural Consultation Service (CCS)

Background: The CCS of the Jewish General Hospital has been evaluating the mental health of immigrants and refugees since 1999. As may be expected, CCS patients from linguistically diverse backgrounds need interpreter services, but how clinical decisions are made to assign interpreters to a given patient are unknown. Furthermore, there are no clinical language proficiency tools available for use in health care settings. Health care literacy tools exist, but before they can be administered to patients of diverse backgrounds, basic verbal language proficiency in English must first be evaluated.

Objectives: Using a retrospective sample of CCS referrals, this study will demonstrate that clinicians overestimate language proficiency in linguistically diverse patients. Then, a simple tool to measure verbal language proficiency, which can be administered quickly and efficiently in clinical settings, will be piloted on a prospective sample of CCS referrals to address this problem.

Hypotheses: 1) The language proficiency of patients will be overestimated by referring clinicians compared to CCS clinicians; 2) The extent to which referring clinicians differ on their estimation of patients’ language proficiency will depend on several variables, including type of referring clinician and institution, patient age (older versus younger), status in Canada (refugee versus immigrant) and level of formal education; 3) The pilot language proficiency questionnaire will, on average, take less than 10 minutes per patient (clinical utility, feasibility) and will be completed by more than 80% of the approached patients who give their consent to participate in the project (clinical acceptability).

Research Methodology and Study Population: Step 1: Retrospective language data on 150 CCS referrals (over approximately five years, 2013-2017) whose mother language is other than English will be gathered by a research assistant from patient charts. Step 2: Prospective language data on approximately 50 CCS referrals (over one year, 2018-19, with anticipated increasing referral rates due to the recent influx of refugees) whose mother language is other than English will be gathered by a research assistant as per Step 1 above. In addition to comparisons of rated language proficiency between referring clinicians and the CCS clinicians, a participant observer will note the dynamics of language use during the consultation: predominant language spoken, language preferences, and how interpreters negotiate clinical communication. Step 3: Based on input from data gathered during Steps 1&2, a pilot language proficiency questionnaire, clinician-rated, brief (less than 10 minutes), and focusing on verbal language, will be drafted by the CCS researchers and administered prior to cultural consultations by a research assistant to 25 CCS referrals (over six months in 2018-19) to estimate feasibility, clinical utility and acceptability of the instrument.

Data Analysis: Descriptive statistics will be calculated for each demographic and study variable. Analysis of Variance (ANOVA) will be used to determine group differences on estimation of language proficiency. Where power considerations allow, variables from Hypothesis 2 that may influence the pattern of results will be analyzed. Measures that are scored categorically (i.e., patient’s need of an interpreter, yes/no) will be assessed using Chi-Square tests. Thematic analysis of qualitative data, gathered from participant observation, will be used to inform the development of the language proficiency questionnaire and to comment on its feasibility, clinical utility and acceptability in preparation for formal empirical testing.

Relevance: Language barriers are linked to poor mental health outcomes that are preventable if clinicians recognize which patients need interpreter services and plan ahead to provide them. A clinical tool to determine basic verbal language proficiency in English, the first of its kind, would make such interventions possible.

Culturally Adapted Education Materials for Families of English-Speaking Minority Patients with Early Psychosis

Psychosis is a serious mental illness that usually begins in adolescence or young adulthood and is characterized by distressing symptoms like hallucinations and paranoia. Psychosis ranks in the top 3 most disabling conditions worldwide. Educating the families of affected individuals is known to make patients feel better, yet many family members of minority patients don’t participate in the education sessions that are offered. Reasons for the lack of participation include not trusting medical authorities and not feeling comfortable to bring up cultural issues like religion, spirituality, and racism. There have been no early psychosis programs that have addressed these problems, so the current study is doing just that.

Over the last two years, researchers have met with leaders and members of English-speaking minority communities, families of English-speaking minority patients with psychosis, patients, and clinicians to understand what changes are needed to make family education about psychosis more acceptable and helpful to people of diverse backgrounds. While it is true that research efforts to date have produced a large and growing body of data, these findings and results need to be prepared for presentation to communities and families. Our knowledge translation activities will include writing plain language summaries of meetings with community and family members to explain what kinds of topics and discussions will facilitate effective care for their loved ones with early psychosis and better collaboration with the clinical team. We will also present statistical findings in a non-threatening and easy-to-access format that will be easy for everyone to understand.

The potential impact of these activities will give community and family members a greater understanding of psychosis, will improve their participation in education seminars, and will contribute to healthier and happier lives of young people with early psychosis.

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Outputs:

• Jarvis, E. G., Desmarais, C., Lang, E., Zimanyi, L., & Leroux-Goyet, S. (March 2023). Family Psychoeducation series [Virtual workshop].

• Khan, S. (March 2023). Looking after our and our Youth's Mental Health. A presentation on caring for our mind, body, and spirit [Presentation]. Amal Center for Women, Montreal, Canada.

• Paquin, V., Pow, R. (March 2023). Training of workers on first episode psychosis L’Annexe is a community organization engaged in the socialization of multicultural young adults with intersectional vulnerabilities [Presentation]. L’Annexe – Ometz Drop-in centre for young adults 16-35, Montreal, Canada.

• Unknown. (Februrary 2023). Exploring the Mental Health Stigma Within the Black Community [Virtual event].

Project extension | Assessment and Implementation of the MedComm Online Interpretation Platform into the Clinical Setting

One-year project extension for a previously funded project. See here.

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Outcomes:

• Unknown. (March, 2023). Role of Medical Students as Interpreters in Bridging Language Barriers in Healthcare Centers: A Scoping Review [Poster presentation]. 19th Annual Crossroads Interdisciplinary Health Research Conference.

Utilizing Multilingual Medical Students and the MedComm Platform to Address Language Barriers in Healthcare

The use of professional medical interpreters is considered the highest standard in medical interpretation. However, there is currently no universal, sustainable, and feasible medical interpretation service offered across McGill-affiliated healthcare sites. Our proposal includes three projects, each addressing the need for accessible interpretation services for patients with language barriers.

First, we would like to deliver a workshop on the basics of medical interpretation to all multilingual medical trainees at the McGill School of Medicine and study the impact of this workshop on students’ knowledge and self-perceived qualification to serve as an interpreter. Second, we would like to develop and implement a series of educational workshops for a wider range of healthcare trainees at the McGill Faculty of Medicine. These workshops will cover the basics of interacting with an interpreter in a medical appointment and will teach the participants how to access interpretation services. Lastly, we want to develop an online and mobile platform for requesting the services of trained student interpreters and conduct a pilot study to test the utility and feasibility of the platform in the clinical setting. Through our work, we also aim to build cultural competency among healthcare trainees by raising awareness of the issue of language barriers, their effects on linguistic minorities, and the importance of availability of professional interpreters.

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Outputs:

1. Unknown. (2021, April). Interpretation Training for Multilingual Medical and Dental Students: A Pilot Study of a Virtual Interactive Workshop [Presentation]. Canadian Conference on Medical Education.

2. Unknown. (May, 2021). Virtual Interpretation Workshop for Multilingual Medical and Dental Students: A Pilot Study [Presentation], MASH/MJM Interprofessional Health Research Symposium.

3. Unknown. (December, 2021). MedComm Platform: A Tool for Managing Requests for Medical Interpreter [Poster presentation, virtual]. Annual 2021 Dialogue McGill Conference, virtual.

4. Unknown. (December, 2021). Working with Interpreters: Virtual Workshop for Medical and Dentistry Students [Poster presentation, virtual]. Annual 2021 Dialogue McGill Conference, virtual.

5. Unknown. (2022, April). Working with Interpreters: Virtual Workshop for Medical and Dentistry Students [Poster presentation]. Ontario Student Medical Education Research Conference.

Improving language awareness in mental health care by engaging clinicians of language diverse patients

Despite the diverse linguistic profiles of patients at inner city hospitals, language barrier between patients and clinical staff remains neglected. Reasons may include lack of awareness of language barrier by clinicians and silencing of barriers by organizational practices and management priorities. From prior research, inpatient psychiatry nurses and medical students are least likely to seek the help of interpreters when faced with patients that don’t speak English or French. Reasons for these practice patterns are unknown.

Developing previous work, this study aims to clarify the quality of language barriers in clinical settings, focusing especially, but not uniquely, on the work of nurses and medical students, to (1) document clinician awareness of language barriers in their patients; (2) explore how awareness of language barriers can be enhanced professionally and institutionally; (3) evaluate the discourses reinforcing language barrier in clinical practice; and (4) assess whether promoting awareness of language barrier results in a measurable increase in documentation of language dynamics in patient charts and a corresponding increase in clinician satisfaction working with language diverse patients in clinical mental health settings. Investigators hypothesize that after focus groups on language barrier over one year on psychiatric services, measurements at Time 1 compared to Time 2 will show (1) a statistically significant increase of clinician awareness of language barriers as measured by mentions of language issues in patient charts and (2) greater clinical satisfaction working with language diverse patients.

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Outcomes were curtailed by the COVID-19 pandemic.

Clinical Measurement of Verbal Language Proficiency in Patients Referred to a Cultural Consultation Service (CCS).

The Cultural Consultation Service of the Jewish General Hospital has been evaluating the mental health of immigrants and refugees since 1999. As may be expected, CCS patients from linguistically diverse backgrounds need interpreter services, but how clinical decisions are made to assign interpreters to a given patient are unknown. Furthermore, there are no clinical language proficiency tools available for use in health care settings. Health care literacy tools exist, but before they can be administered to patients of diverse backgrounds, basic verbal language proficiency in English must first be evaluated. Using a retrospective sample of CCS referrals, this study will demonstrate that clinicians overestimate language proficiency in linguistically diverse patients. Then, a simple tool to measure verbal language proficiency, which can be administered quickly and efficiently in clinical settings, will be piloted on a prospective sample of CCS referrals to address this problem.