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Working with the Hmong Population in a Genetics Setting: an Interpreter Perspective

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Working with the Hmong Population in a Genetics Setting: an Interpreter Perspective J Genet Counsel (2018) 27:565–573 DOI 10.1007/s10897-017-0153-0 ORIGINAL RESEARCH Working with the Hmong Population in a Genetics Setting: an Interpreter Perspective Meghan Krieger1 & Aime Agather2 & Kathryn Douglass3 & Catherine A. Reiser1 & Elizabeth M. Petty1 Received: 5 August 2016 /Accepted: 31 August 2017 /Published online: 24 September 2017 # National Society of Genetic Counselors, Inc. 2017 Abstract The aim of this pilot qualitative study was to de- for future studies and suggestions to improve communication scribe the experiences and beliefs of medical interpreters when with Hmong patients are explored. working with genetic counselors and other genetic providers caring for Hmong patients who are not native English Keywords Cultural perspectives . Language barriers . speakers. Specific goals were to identify interpreters’ thoughts Interpretive services and perceptions on (a) their roles during sessions, (b) unique challenges in a genetics session, (c) knowledge genetics pro- viders need when working with Hmong patients and inter- Introduction preters, and (d) supports and training needed to effectively interpret in a genetics setting. Hmong medical interpreters The Hmong population in the United States has been rapidly from Wisconsin and Minnesota were invited by email to par- growing since the mid 1970’s. Based on the 2012 American ticipate in the study. Six were interviewed by telephone. Community Survey (ACS) microdata samples, the population Participants had worked with a variety of providers including of Hmong is estimated to be 265,415 and growing. This pop- geneticists, genetic counselors, primary care physicians, and ulation is mainly concentrated in California, Minnesota and oncologists. Factors identified by Hmong interpreters that Wisconsin (2010 U.S. Census Hmong Populations). The ACS made interpretation of content difficult in clinical genetics estimated that about 43.9% of the Hmong population in the sessions included: time constraints, technical terms, and United States speaks English less than Bvery well^ (2012 U.S. unique cultural perspectives of Hmong patients. While all Census Bureau American Community Survey). Language respondents felt their primary role was to interpret ses- barriers can pose a great disadvantage to non-English speakers sion content as close to verbatim as possible, there was in the United States who are trying to access medical care. notable variation in the description of their interpretation Studies have shown that language barriers universally cause style and other perceived roles in the genetic counseling issues in: access to health care, comprehension and adherence, session. Cultural issues genetics providers could consider quality of care, and patient satisfaction (Jacobs et al. 2006). when working with Hmong patients and different style issues These challenges can vary based on the native language spo- when working with Hmong interpreters are discussed. Ideas ken. The Hmong language lacks established vocabulary words for many medical terms. Terms like Bcancer^, Bchromosome^,andBgene^ do not exist in Hmong and may * Meghan Krieger present a difficult barrier for interpreters to overcome. Efforts [email protected] have been made by Hmong interpreters to establish specific terminology to use to prevent miscommunication (Xiong 1 University of Wisconsin School of Medicine and Public Health, Rm 2011). However, these efforts have been limited and little 333 Waisman Center, 1500 Highland Avenue, Madison, WI 53703, knowledge is known of their impact. Being able to translate USA these concepts effectively depends greatly on the ability of the 2 Medstar Washington Hospital Center, Washington, DC, USA interpreter and provider to work together harmoniously and 3 North Memorial Health Care, Robbinsdale, MN, USA prevent information from getting lost in translation. 566 Krieger et al. The cultural beliefs within the Hmong population have in English and the target language. Both organizations then previously been studied and differ from the Western medical require an oral exam to obtain credentialing in the respective cultural beliefs (Smalkoski et al. 2012). Traditionally, the per- language. For languages that do not have an oral exam for ceptions of the biology of disease for the Hmong are more credentialing, the CCHI offers a written examination for an often associated with natural or spiritual beliefs. Wilder Associate Healthcare Interpreter Credential (AHI) (National Research Center (2000) found that about 66% of Hmong in- Council on Interpreting in Health Care 2013). This exam mea- dividuals practice Shamanism, the belief in the strong power sures the following skills and abilities: managing the of spirits in causing and preventing disease. These individuals interpreting encounter, understanding healthcare terminology, will typically reach out to shaman healers and other natural interacting with other healthcare professionals, preparing for remedies before considering any Western medicine. Family an interpreting encounter and cultural responsiveness. After structure is also an important factor in how the Hmong make receiving these credentials, continuing education and work medical decisions. Lee and Vang (2010) showed that these experience are required for credential maintenance (Certified patriarchal values can be a barrier for Hmong Americans Commission for Healthcare Interpreters 2014). This process and hinder Hmong women from seeking appropriate care provides reassurance to institutions and patients of the quality and screening. and consistency of the medical interpretation. Requirement of The role of a medical interpreter is not universally clear being either a certified or AHI credentialed interpreter varies among interpreters, providers and patients. Hsieh and from institution to institution. Kramer (2012) examined the role of an interpreter from the Agencies employing Hmong medical interpreters typically conduit model perspective, which would describe the inter- do not require AHI credentialing, only that they pass a test in preter to be a Blanguage-transferring machine^ and compared their target language. These interpreters therefore vary tremen- it to the utilitarian model which identifies the role of the inter- dously in the amount of medical training they have received, preter as being more complex, where the interpreter has a with some having a few hours of training to those with a mas- more active role. From their interviews with medical inter- ter’s degree in interpreting (Thomson 2010). Some Hmong preters, it seems that most providers use the interpreter as a interpreters get credentials in Hmong court interpreting which passive instrument to convey their medical knowledge. It is requires a two day orientation on court interpreting, a written clear that the success of the work of an interpreter is greatly examination in English to test English proficiency, court- influenced by the beliefs that the interpreter, their clients, and related terms and ethics, and pass an oral examination to test the providers have on the role of an interpreter (Hsieh and proficiency in English and the target language (Wisconsin Kramer 2012). The National Council on Interpreting in Court System 2014). Despite efforts over the past 20 years to Healthcare (NCIHC 2013) has outlined guidelines on the stan- develop national medical interpreter standards for training and dards of practice which encompass accuracy, confidentiality, certification, a system has yet to be in place to measure com- impartiality, respect, cultural awareness, role boundaries, pro- petence and quality of care (Youdelman 2013). fessionalism, professional development and advocacy for in- Many genetic conditions vary in prevalence based on eth- terpreters in health care. These standards of best practice, nic group. Van Calcar et al. (2007) showed that genetic con- which neither directly fit into the conduit model nor utilitarian ditions like 2-methylbutyryl-CoA dehydrogenase deficiency model, help to ensure that the interpreters are fulfilling the (2-MBAD) are increased for the Hmong population in duties of the profession while ensuring consistency of perfor- Wisconsin. Other conditions are known to have an increased mance and consideration of ethical principles (National risk in Asian Americans and specifically Hmong populations Standards of Practice for Interpreters in Health Care 2005). as well. Some of these are: coronary artery disease, chronic The Certification Commission for Healthcare Interpreters kidney disease, diabetes, various cancers and alpha and beta (CCHI) and National Board for Certification of Medical thalassemia (Smalkoski et al. 2012). The majority of these are Interpreters are the two national organizations that provide a result of genetic and environmental factors. Hmong certification and credentials to medical interpreters. Neither Americans have a mortality rate two times greater than Non- organization credentials Hmong interpreters; CCHI only cre- Hispanic White individuals for certain types of cancers like dentials Spanish, Arabic and Mandarin interpreters, while the stomach, cervical and liver cancer. Proper education is National Board for the Certification of Medical interpreters important to help patients to understand the cause, credentials Spanish, Russian, Mandarin, Cantonese, Korean recurrence risks and need for screening for certain genetic and Vietnamese interpreters. The process of credentialing conditions. Lee and Vang (2010) showed that factors like through either organization
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