NHANES Interpreter Guidelines: Effective Communication with Limited English Speakers, Schemes and Mind Maps of English

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Interpretation Guidelines

November 2006

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TABLE OF CONTENTS

Section Page

I NHANES SP Languages ................................................................................. 1 II Interpreter Definition and Clarifications.......................................................... 2 II.1 Interpret vs. Translate ......................................................................... 2 II.2 Common False Assumptions .............................................................. 2 III NHANES Interpreter and Examiner Protocol.................................................. 4 III.1 Interpreter Protocol ............................................................................. 4 III.2 Examiner Protocol .............................................................................. 7 IV Non-MEC Staff Interpreters ............................................................................ 10 IV.1 Spanish Language SPs ........................................................................ 10 IV.2 Other Foreign Languages.................................................................... 10 IV.3 Non-MEC Staff Interpreter Orientation.............................................. 11 V Westat Bilingual Certification ......................................................................... 12 VI NHANES Translation Process......................................................................... 13 References........................................................................................................ 14

List of Appendixes

Appendix

A National Health and Nutrition Examination Survey (NHANES) Interpreter Protocol............................................................................................................ A-

II. Interpreter Definition and Clarifications

II.1 Interpret vs. Translate

The terms “interpret” and “translate” have similar definitions and are often used interchangeably:

„ Interpret – To explain the meaning of; to conceive the significance of; to translate orally; and „ Translate – To render in another language; to put in simpler terms; to explain.

The major difference between the two terms is that an interpreter relays a message orally, whereas a translator works with the written word. Consequently interpreters and translators develop different skill sets. Interpreters must have the capacity to work “on the spot” and convey spoken words from one language to another, in both directions. In contrast, translators require strong writing abilities and will typically convert written text from a second language into their native language, in one direction.

II.2 Common False Assumptions

Two false assumptions are commonly made with regard to language interpretation:

1. False: Bilingual = Interpreter

Most people incorrectly assume that a bilingual person can interpret effectively by virtue of being bilingual. In truth, bilingual individuals who have not received interpreter-specific training are more likely to add or omit information in the exchange between the examiner and the SP. They also have a tendency to interject their own opinions and assumptions into the discussion, resulting in the transmission of incomplete and/or inaccurate information. This introduces bias in the study data and potentially threatens the SP’s safety and wellbeing. In addition, untrained interpreters are more apt to engage in conversations with the SP or examiner that are unrelated to the examination. These extraneous exchanges or “side conversations” are counterproductive to the survey: time is wasted during the exam; both the examiner and SP become distracted from the task at hand; and the SP may feel ignored or even offended.

Under ideal circumstances SPs should not rely on their own family members or friends as interpreters, for the same reasons described above. Moreover, using interpreters with whom the SP has an existing relationship places the SP’s confidentiality at risk. Despite these factors, SPs often prefer to use a family member or friend to interpret for them. Some SPs may even refuse to participate in the study unless a relative or friend accompanies them to the MEC as their personal interpreter. For confidentiality purposes, survey staff will conduct MEC examinations on these SPs with the exception of portions involving disclosure of sensitive information. For obvious reasons, children must never be used as interpreters.

2. False: Working Effectively Through an Interpreter Comes Naturally

How to work through an interpreter is often taken for granted. Using an interpreter to communicate is not as straightforward as is commonly assumed. In the context of NHANES, examiners who have little experience working through interpreters are more likely to avoid speaking to the SP. This alienates the SP by converting the exchange into a dialogue solely between the examiner and the interpreter. Side conversations also become more tempting when the examiner and interpreter exclude the SP from the interaction. Additionally, when the examiner addresses the interpreter instead of the SP, this ignores the fact that many SPs can understand English despite limited English-speaking ability. Initially it may feel strange for the examiner to address the SP directly, for fear of being impolite. In reality the opposite is true: It is disrespectful to avoid speaking to the SP on the assumption that she or he cannot understand.

Examiners who are unfamiliar with language interpretation tend to speak in long segments. Or they speak too fast for interpreters to completely and accurately express the information. Also, individuals often make the unconscious mistake of patronizing or infantilizing adults with limited English proficiency. Another common oversight is to raise one’s voice when the issue is a language barrier rather than a hearing impairment.

avoiding eye contact encourages the SP and examiner to address each other, and discourages side conversations.

The interpreter’s position in the room can facilitate the discussion between the examiner and the SP. For example, one option is to place yourself in the middle of a triangle among them. Alternatively, standing beside either the SP or the examiner can help stimulate eye contact between the two. For some examination components, the size and layout of the MEC room will ultimately determine where the interpreter stands. Either way, the goal is for the SP and examiner to engage each other.

4. Use Existing Translations

For Spanish interpretation, do not offer your own translation when the Spanish version is already provided. For non-Spanish interpretation, translate the English text out loud. In both cases, it is not necessary for the examiner to read the English translation before the interpreter begins. However, if the interpreter cannot read well enough, then the examiner should read the English text out loud and have it interpreted.

In many NHANES components hard copy scripts are posted on the exam room walls for the examiner’s reference. The scripts consist of either standardized (required word-for-word) or suggested language depending on the examination protocol. Whenever possible, the Spanish translation is provided for wall scripts and language that the examiner says to the SP from the computer screens. To view the English or Spanish version on the screen, the examiner presses ctrl-E or ctrl-S, respectively. Copies of the English and Spanish examination scripts are also provided separately to the MEC staff interpreters for their reference. Adherence to existing standard or suggested translated scripts is required as this provides quality control in three ways:

1. Ensures protocol standardization;
2. Provides consistency across interpreters; and
3. Prevents wasted exam time due to unfamiliar vocabulary. 5. No Side Conversations

Avoid extraneous conversations with the examiner or SP during the examination. Side conversations between the interpreter and the examiner are impolite and unprofessional whether or not the SP fully understands what is spoken. Regardless of their language proficiency, people can sense meaning

from others’ body language and intonation. Outside discussion between the interpreter and SP during an exam wastes time. It is also distracting and discourteous to the examiner. However, the SP will often initiate conversation with the interpreter. To politely dissuade the SP, you can simply offer to talk more after the exam is finished. In such cases, always be sure to inform the examiner so that he or she understands what is going on.

6. Basic Responsibilities

In addition to the procedures described above, NHANES interpreters are expected to assume the following basic responsibilities:

Professionalism and Confidentiality – The interpreter must exhibit professionalism at all times and maintain the confidentiality of the examiner-SP dialogue. As well as adherence to the interpreter protocol, important aspects of professionalism include: being courteous but not overfriendly; being honest but tactful; and showing respect to the examiner and the SP.

Accuracy and Completeness – The interpreter should accurately and completely convey statements made by the SP and the examiner. This does not mean that a literal translation is necessarily appropriate. Sentence constructions inherently vary from one language to another, and certain phrases do not carry the same meaning across multiple languages. In short, interpreters must accurately relay the full meaning and spirit of what is said, rather than a literal interpretation per se, which conveys all of the words but not always all of the meaning.

The interpreter needs to communicate everything that is spoken by the SP and examiner. The same applies to hard copy scripts that the examiner asks the interpreter to read to the SP. Interpreters sometimes make the mistake of omitting statements that they judge as unimportant; or summarizing statements instead of providing the full translation. However, the interpreter’s role is not to decide what statements are relevant - no matter how familiar the interpreter becomes with the exam component. Doing so withholds information from the examiner who is the person responsible for the component. In the end, not providing full disclosure may jeopardize the SP’s safety or wellbeing.

Cultural Bridge and Knowing Limits – Interpreters need the ability to serve as a cultural bridge between the SP and examiner, while keeping within the limits of the interpretation process. Besides repeating what the SP says to the examiner, certain instances may call for the interpreter to explain the cultural context of a specific statement. However, great care should be taken to provide only the essential, cultural background information. Interpreters must always refrain from adding personal

2. Address SP Directly

Speak to the SP as if he or she understands everything. The examination should not consist of conversations between the examiner and the interpreter about the SP. The examiner should address the SP directly (e.g., “Do you have…”) instead of the interpreter (e.g., “Ask him if he has…”); and the interpreter should answer as if he or she were the SP (e.g., “Yes I have…”). This keeps the examination correctly centered on a dialogue between the examiner and SP, the same as with exams involving English-speaking SPs. Also, maintaining the interpreter strictly as an information conduit treats the SP with professionalism and respect, and facilitates complete and accurate data collection.

3. Speak at a Moderate Pace, in Shorter Segments

Do not make many statements before allowing the interpreter to repeat them. When the interpreter is not able to properly convey everything you say during the exam, the likelihood of losing study data increases. The transmission of incomplete information or misinformation can also threaten the SP’s health and safety. Finally, if the interpreter needs to ask you to repeat yourself, this will most likely result in frustration for both parties, repeated interruption of the exam flow, and wasted survey time. By speaking at a reasonable pace and in shorter segments, the examiner gives the interpreter the best opportunity to relay information correctly and efficiently.

4. Cue Interpreter

Pause or glance at the interpreter to prompt him or her when to interpret. Do not assume that the interpreter automatically knows when to begin speaking. While you are addressing the SP, the interpreter focuses on memorizing your speech to be able to repeat it to the SP in the other language. Also, the interpreter constantly monitors your communication to ensure that you are not saying too much for him or her to remember precisely. With this in mind, pause purposefully after speaking a few phrases to let the interpreter know when to begin. A quick look or nod toward the interpreter also serves as a helpful cue.

For Spanish interpretation, point the interpreter to the Spanish script and ask him or her to read it out loud. You do not have to say the English version first. Allow the interpreter to read the existing translation, no matter whether the script is standardized or suggested.

For non-Spanish interpretation, direct the interpreter to the English script and ask him or her to translate the text out loud. As in the case of Spanish, you do not have to say the English version first. However, if the interpreter cannot read well enough, then read the English script out loud and have it interpreted.

5. No Side Conversations

Avoid unnecessary conversations with the interpreter during the examination. To reiterate, side conversations between the examiner and the interpreter are impolite and unprofessional, regardless of whether or not the SP fully understands what is spoken. Worse, some SPs may assume the conversation is about them and feel offended.

The identification of appropriate interpreters (i.e., excluding the SP’s relatives or friends) can be a difficult, if not impossible, task to fulfill at times. MEC exams that remain incomplete due to a language barrier are coded in the Integrated Survey Information System (ISIS) as “Partial” or “Not Done” with a reason of “Communication Problem.”

IV.3 Non-MEC Staff Interpreter Orientation

When non-MEC staff interpreters arrive at the mobile examination center, the MEC manager, or staff assigned by the manager, provides a brief orientation and tour of the MEC. To allow time for the orientation, interpreters are asked to arrive prior to the beginning of the first session for which they will interpret. During the orientation, interpreters are introduced to MEC staff members and to the various examination components that will require their assistance. At this time emergency exits and other critical safety information are explained. Moreover, if time permits, the MEC manager or other assigned staff will review the protocol described in Section III. Finally, the MEC manager and Chief Health Technologist will be available to answer any questions the interpreter has regarding the survey or the procedures he or she is expected to follow.

The NHANES field office staff will provide non-MEC staff interpreters with a copy of the NHANES Interpreter Protocol (see Appendix A) prior to interpreting for MEC examinations. This document is a shortened version of the NHANES Interpretation Guidelines. The Interpreter Protocol summarizes the basic procedures for how to interpret within the context of the MEC environment.

V. Westat Bilingual Certification

NHANES field staff members who are not certified by Westat as English-Spanish bilingual must use an interpreter to conduct exams on Spanish-only-speaking SPs. This policy was established by NCHS in conjunction with its Ethics Review Board (ERB). In accordance with this policy, Westat utilizes a certification process for classifying field staff as English-Spanish bilingual. The goals of the certification are:

„ To ensure that Spanish-speaking SPs who participate in the survey receive the same access and treatment as English-speaking SPs; and „ To establish a minimum level of Spanish proficiency among bilingual survey staff.

English-Spanish bilingual certification is required for permanent and contracted survey staff to serve as interpreters during the conduct of MEC examinations. The certification process is open to all survey staff and consists of an oral and written assessment administered through Westat. There is no certification process for non-Spanish languages.

Noncertified examiners should not use Spanish to direct an SP in any way during an examination. This includes parts of study protocols that contain either standardized or suggested scripts, or unscripted language. The noncertified examiner will address the SP directly in English, and the interpreter will relay information between the examiner and SP. The MEC anthropometry exam is the only exception: due to the nature of this component, it would be acceptable for a noncertified examiner to use Spanish words during the exam to direct the SP for the purpose of positioning for body measures. However, a Spanish interpreter must always be assigned to the component as long as the examiner is not certified.

Any examiner who is not Westat-certified as bilingual should feel free to use Spanish to communicate with SPs when he or she is not conducting an exam. Motivation by staff members to improve their Spanish proficiency is welcomed outside of exam components. Conversations with SPs, friends, and family members in the MEC reception area, in the hallways between exams, or with Spanish- speaking staff offer excellent opportunities to practice. Moreover, conversing with Spanish-speaking SPs tends to contribute very positively toward their experience in the MEC.

REFERENCES

American Heritage College Dictionary. Third Edition, Boston, New York, Houghton Mifflin Company, 1997, pp. 711, 1437.

Bridging the Gap: A Basic Training for Medical Interpreters. Interpreter’s Handbook, Third Edition, Jan.,

Cross Cultural Health Care Program, Seattle, WA, web site: www.xculture.org.

Medical Interpreter Training. Arlington Free Clinic, Arlington, VA, Jan., 2000.

Appendix A

National Health and Nutrition Examination Survey

(NHANES)

Interpreter Protocol

A-

4. Use Existing Translations

For Spanish interpretation, do not offer your own translation when the Spanish version is already provided. Read the script out loud, word for word, exactly as it is written. For interpretation of another foreign language, translate the English text out loud. In both cases, it is not necessary for the examiner to read the English translation before the interpreter begins. If the interpreter cannot read well enough, then the examiner should read the English text out loud and have it interpreted.

5. No Side Conversations

Avoid unnecessary conversations with the examiner or SP during the examination. Irrelevant discussions or “side conversations” between the interpreter and the examiner are impolite and unprofessional whether or not the SP fully understands what is spoken. However, the SP will often initiate conversation with the interpreter. To politely dissuade the SP, you can simply offer to talk more after the exam is finished. In such cases, always be sure to inform the examiner so that he or she understands what is going on.

6. Basic Responsibilities

All NHANES interpreters are expected to assume the following basic responsibilities:

Professionalism and Confidentiality – The interpreter must exhibit professionalism at all times and maintain the confidentiality of the examiner-SP dialogue. As well as adherence to the interpreter protocol, important aspects of professionalism include: being courteous but not overfriendly, being honest but tactful, and showing respect to the examiner and the SP.

Accuracy and Completeness – The interpreter should accurately and completely convey statements made by the SP and the examiner. This does not mean that a literal translation is necessarily appropriate. Interpreters must accurately relay the full meaning and spirit of what is said, rather than a literal interpretation per se, which conveys all of the words but not always all of the meaning.

The interpreter must communicate everything that is spoken by the SP and examiner. The same applies to hard-copy scripts that the examiner asks the interpreter to read to the SP. The interpreter’s role is not to decide what statements are relevant—no matter how familiar the interpreter becomes with the exam component.

A-

Cultural Bridge and Knowing Limits – Interpreters need the ability to serve as a cultural bridge between the SP and examiner, while keeping within the limits of the interpretation process. Besides repeating what the SP says to the examiner, certain instances may call for the interpreter to explain the cultural context of a specific statement. However, great care should be taken to provide only the essential, cultural background information. Guessing or making up terms is not acceptable. If the interpreter does not understand something that was said, he or she should ask for clarification in order to provide a complete and accurate interpretation.