Handouts in multiple languages enhance education of immigrant populations

Systems partner to better educate patients with limited English proficiency

Now there is an on-line inventory of about 120 dual language (English and a foreign language) health information documents in numerous languages. The web site, www.healthinfotranslations.com, is a result of a collaboration between three major health care systems in Columbus, OH, that includes The Ohio State University Medical Center, Mount Carmel Health, and OhioHealth.

"This project is really an excellent use of our resources in terms of allowing more languages and a greater variety of handouts since that is the focus of the project. We were very glad to get on board and we try to think of OhioHealth and Ohio State as our neighbors rather than our competitors, even though there is some competition," says Karen Guthrie, MS, RN, patient education specialist at Mount Carmel Health.

Each health care system could only afford to translate a few handouts each year, but once they formed a partnership the number swiftly multiplied. Diane C. Moyer, MS, RN, consumer health education manager at The Ohio State University Medical Center, says she would get calls from clinical areas requesting teaching sheets in certain languages but had to be very selective when determining what to translate because her budget was limited.

The idea to form a partnership came about when the patient education coordinators from each system began to meet informally to network, discuss issues, and offer each other support. During these meetings, they discussed the cost of translating material and the possibility of sharing translated documents only to discover that much of their inventories were exactly the same.

In addition, no one had a consistent plan for translating handouts. Mostly they were translated when someone asked and they did not provide consistent education in foreign languages across all diagnoses, says BJ Wingert, MS, RN, patient education specialist at OhioHealth.

The three patient education coordinators decided to create a system for writing easy-to-read documents that could be translated into the most frequently needed foreign languages in central Ohio and shared across systems. When they approached their administrators with the idea, all agreed to support it.

A grant from the Columbus Medical Association Foundation was obtained to launch the project, which included creating a web site as a means for distributing the information. Grant money also covers the cost of translating the documents and writing grant proposals is an ongoing process. The three health care systems incorporated the work each of their patient education coordinators do on the project into their job descriptions so the cost of their labor is covered in their salaries.

The web site was launched in April 2005; however, work on the project began about three-and-a-half years ago.

A part-time project assistant, Angie Barnes, was hired to help create the English version documents that are sent out for translation. Grant funding covered her salary the first year and Ohio State has agreed to pay for her services the second year. That health care system also allows its technical editor to help with the web site.

A plan is formed

To determine the type of foreign language documents that would be most valuable, the patient education coordinators surveyed clinicians throughout central Ohio. In addition to contacting clinicians within each health care system, they sent the survey to the health department and to various clinics. They tried to get input from physicians, dietitians, and educators including nurses that worked at free clinics.

"Much of the responses we got were related to diagnostic tests, things that were done very frequently; but there were no materials available such as EKGs, chest X-rays, and colonoscopies," says Moyer.

Focus groups within various immigrant communities also were formed in order to find out what they thought the needs were.

"One of the things we found was they often didn't know what things were called so they didn't know how to ask us for information on certain health issues," says Moyer.

Interpreters were interviewed to determine what they thought were the highest needs and the patient education coordinators reviewed the list of requests for translated patient education information they had received over the years.

In light of the information gathered, diagnostic tests became the first set of handouts targeted with a goal to translate each one into nine languages. At the beginning of the project one of the coordinators would search the Internet to see if the material was available in foreign languages either on-line or through some other source. If a handout was found in English and another language the readability level was evaluated.

"Generally we found there wasn't much of anything available in diagnostics except for a few things in Spanish. Often the things that were available were not at a readability level we were hoping for. We haven't been able to do readability on the translated documents only on the English version but we have been striving for a sixth grade level or below," explains Moyer.

To create a document, Barnes is given all the information on a topic from each system and she merges it to form a rough draft.

"If one or more of us have something, we use it as a takeoff point; but we have written new materials from scratch if we don't have it within our own systems," says Guthrie.

Simple, easy-to-read handouts are vital. The community focus groups said the handouts should be short. Also the coordinators learned that within the Somali- and Spanish-speaking populations, many people cannot read well due to limited schooling. Because health literacy is an issue with the English-speaking population in central Ohio, the patient education coordinators determined that foreign language materials should be simplified even more.

Moyer says that in addition to information on preparing for diagnostic tests patients are told what to expect, because in most of the countries from which they immigrated preventive care is not common. "Mammograms, pap smears, and those type of things are not routinely done in many of the countries," she explains.

Establishing quality checks

Once the handouts were completed in English, they were given to a translation service for interpretation. The company used is one that all three health care systems had worked with in the past both for translation and interpretive services.

"They do some quality checks of the materials. None of the patient education coordinators in this project are multilingual so we don't know what the materials should look like when we get them back. Therefore, we have to have some way to check them," says Moyer.

The company chosen has one person translate the material to the foreign language and another person translates it back to English to make sure the content is correct before the handout is sent to an editor who reviews it. The copy is sent to a proofreader for a final check.

To make sure the handouts are consistent the translation service has one person act as coordinator to assign the material to the same translators. These translators know the copy needs to be written in more conversational language than formal. If there is a question about a word choice they call to see if the wording should be changed. For example, one translator called to ask about the use of the word "cookie" because in the foreign language it would be perceived more as what Americans know as crackers.

The detailed translation process helps protect against liability issues. "We pay a little higher premium on our translation because we go through a company that does back translation and then they have it proofed by two other people so there is quite a bit of checking on our documents. This is done for accuracy. We put them on the web site as a PDF so people can't change them," says Wingert.

The web site is external rather than funneled through the web of one of the health care systems. In addition, the colors used and any other identifying features are different from any of the participating institutions. "We have been very aware of the politics and have looked at those issues," explained Wingert.

The translations are submitted electronically and new software had to be purchased in order to accurately portray the various fonts of the foreign languages.

A web site was selected to distribute the translated handouts because it was not only the easiest way to share the material between the health care systems but also with other health care entities in central Ohio. "If we are really thinking about the patient we would like them to have the material at all points of care," explains Wingert.

She says it is great for patients to get the same information at the physician's office or clinic as they do when they come to the hospital for a test or treatment. While the materials target immigrant populations in central Ohio, clinicians can access the handouts anywhere. Guthrie says all agreed the materials should be free without copyright restrictions. They had all experienced the frustration of trying to find materials in foreign languages only to have them cost money or not have an English version paired with the translation.

In addition, a lot of time, energy, and money have been invested in the project so it is important that it is used, says Wingert.

To help promote it within her health care system, she distributes stickers with the web address to be placed on computers. She has attended nursing meetings to speak about the web site and written about it in physician and all-hospital newsletters.

Guthrie keeps cards with web site information in her office, which is located within a community health information center. She also distributes these cards to all new employees. "Getting the word out is an ongoing effort," she says.

Since the site was established it has been getting an increased number of hits. In May 2005 it received 43,330 hits; in October 2005 the number was 96,820.

Foreign language handouts are increasingly necessary. It can be difficult to justify the expense when only two or three patients a month may need the material, says Moyer. Yet in the community at large the numbers and the need add up.

As long as grant funding can be obtained the project will press forward. Guthrie says once the diagnostic tests were completed they would begin creating handouts on general health issues.

"We feel we will have a building phase for a few years and then a maintenance phase," says Guthrie.


For more information about the project to improve the overall health of limited English proficiency patients through the distribution of translated materials, contact:

  • Karen Guthrie, MS, RN, patient education specialist, Mount Carmel Health, 5975 East Broad St., Columbus, OH 43213. Phone: (614) 234-6062. E-mail: kguthrie@mchs.com.
  • Diane C. Moyer, MS, RN, consumer health education manager, The Ohio State University Medical Center, 1375 Perry St., Room 524, Columbus, OH 43201.
  • BJ Wingert, MS, RN, patient education specialist, OhioHealth, 3535 Olentangy River Road, Columbus, OH 43214. Phone: (614) 566-5613. E-mail: bwingert@ohiohealth.com.

The web site features handouts in English as well as foreign language versions including African French, Chinese Simplified, Chinese Traditional, Hindi, Japanese, Korean, Russian, Somali, Spanish, and Ukrainian.

Topics covered include diagnostic tests; diseases and conditions; exercise and rehabilitation; food and diet; general information; home care; pain and comfort; pregnancy and baby care; safety; stress and coping; and surgery and treatments.