Language Access Part 2: Language Access in WNC - WNC Health Policy Podcast Ep. 5
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Under federal law, language access is a legal obligation for all recipients of federal funding. However, because “many healthcare providers are not aware of their responsibility, have not prioritized the issue, or have not been held accountable through consistent enforcement of these laws,” language barriers remain a significant challenge for many Western North Carolinians.
Home to over 70 different languages and high levels of illiteracy, communication barriers in healthcare facilities make accessing healthcare difficult for a large portion of Western North Carolina.
Between differing spoken languages, cultural contexts, physical means, and literacy, language access is one tool that can improve health outcomes in WNC. To learn more about language access in our region, NCCHW's audio producer, Andrew Rainey, speaks with Buncombe County’s Language Access Coordinator, Aaron Vidaurri, the Health Access Programs Manager at the WNC Medical Society Interpreter Network, Rosalia McHattie, and co-founder of the Cenzotle Language Justice Cooperative, Monse Ramirez, in 'Part 2' of this WNC HPI podcast miniseries.
Transcript
WNC HPI Podcast: Language Access Part 2: Language Access in WNC
3/18/2024
AR: Andrew Rainey
RM: Rosalia McHattie
MR: Monserrat Ramirez
AV: Aaron Vidaurri
Rosendo: Empieza a encontrarse con muchas dificultades. . Lenguaje es el primero: idioma, la barrera. 2, no saber adónde acudir. . . en caso de que se infirmen. . . entonces la barrera del lenguaje y no saber dónde acudir. . .
You start finding yourself with a lot of difficulties. Language is the first one: language, the barrier. The second, not knowing where to turn. . . in case they get sick. .. so, it’s the language barrier and not knowing where to turn.
Introduction:
AR: You're listening to the Western North Carolina Health Policy Initiative podcast. I'm Andrew Rainey. In each installment we’ll speak about different public health strategies for improving health and well-being in Western North Carolina (WNC).
Recorded between the studios of AshevilleFM and the mountainous internet waves of Appalachia, in this installment, Part 2 of a conversation about language access and healthcare in WNC.
In Part 1 of this series on language access, we got a big picture of the topic, including 3 different groups it impacts: speakers of different languages, folks with auditory or visual challenges, and folks who struggle to read or write, whether medical jargon or a name . . .
We heard how it’s essential to healthcare access and quality, that it’s a federal law, and how it can be approached with a lot of different tools, including: translations, interpreters, various technologies, infrastructure, bilingual staff, and CHWs.
If you’re new to this conversation and listening on the HPI website or a podcast app, I recommend you listen to Part 1 first. However, if you’re listening on the radio, stick around and know that some of your questions may already have been answered in the last episode.
As we heard at the very beginning from CHW Rosendo, now, in part 2, we’ll hear more about how language access looks in WNC - including who’s impacted, what’s working well, and regional challenges.
After this episode, we’ll keep up the conversation on language access in Part 3 where we’ll hear about recommendations and resources to learn more on how to improve services in our region. . . . .
If you’re coming back to the show, you may remember that we’re joined by 3 different guests from right here in WNC. Let’s have them introduce themselves again:
RM: My name is Rosalia McHattie, I’m the Health Access Programs Manager at the Western Carolina Medical Society
MR: Hi my name is Monserrat Ramirez I’m one of the founding members of Cenzontle Language Justice Cooperative.
AV: My name is Aaron Vidaurri. I’m the Language Access Coordinator for the Buncombe County Health and Human Services.
AR: As a disclaimer, all three guests were recorded at separate times! While everyone is featured in each installment of this series, different sections will feature different guests more heavily.
WNC
AR: You may remember from Part 1 of this series, that providing language access services is integral to effective healthcare, and without it, patients face terrible health outcomes.
AV: Yeah, it can be super extreme as far as the outcomes, you know like I said death, mistreatment. . . if the dosage is wrong. . . or it could be like with a frequency, having it misread where it's like ‘3 times a day’ vs ‘3 pills once a day.’ It could be smaller instances that don't seem that impactful, but it could lead to mistrust and then them not wanting to use health systems.
AR: So now in Part 2, we’ll dig into what language access looks like for WNC by getting some more information about who’s impacted here, whats working well, and what particular challenges we have. Of the 3 different groups impacted, let’s start with spoken languages. Aaron, how do we know the size of this issue?
AV: So yeah, so one of the options that’s out there is from the census. . The 2 points of data that we focused on when we were trying to figure out languages in the area was “speaking a language other than English in the household” and then the second data was “the ability to speak English.” So then you can see it will break down, ‘what are the main languages outside of English that are spoken?’ and then you can see within that language how many people say that they speak English ‘well, not very well, or not at all.’
AR: From these two data points, the HPI team found that approx. 7% of WNCians, as defined by Dogwood Health Trust’s parameters of the 18 western most counties, speak a language other than English in their households. That’s around 70,000 people. A little over half of the folks in this group have proficiency using English, perfectly bilingual or not, but regardless of proficiency, when a different language is preferred at home, there’s a lot of potential for misunderstanding when say, a person’s best means of describing symptoms may not be understood by a provider. . .
The other section of that group, about 3% of all of WNC, are considered to have limited English proficiency (LEP). This group absolutely requires language services.
Although these data points help us get a general idea for spoken language needs, the census data on language does have a number of limitations when understanding the size of these populations, including vague language groups that lump many languages together, inconsistent data entry across different counties, difficulty reaching communities with language challenges in order to collect data, and the frequency of data collection when it does exist:
AV: It’s not always going to be the most current information but it’s a good gauge in what’s happening. . . like yeah maybe we have a high level for this language, but the vast majority of them are falling in “very well,” so maybe like if you have a small budget, there might be another language where very few of them say they speak English ‘well,’ so that’s where you’d want to focus getting the needs. . .
AR: So, we have the wide reaching and not totally descriptive census data that gives us a rough foundation for spoken language access needs in WNC. When we want to get specific though, it’s best to go directly to the field. . . Luckily, we have one other source here with us who can help us put it together!
Rosalia, the WIN interpreter network travels all across WNC offering interpretation and translation services. What languages are being requested here?
RM: Definitely Spanish is the most requested, followed by Russian, and Ukrainian in the area.
AR: According to ‘Buncombe County Schools,’ there are over 70 different languages spoken in our region’s most populous county, but as Rosalia mentioned, Spanish, Russian, and Ukrainian are the biggest non-English-speaking language groups, and with current projections, they are likely to keep growing. . .
AV: I was at a meeting in Raleigh and they had someone from the State Demographers Office and they had been working on projections for population growth like 10, 20 or 30 years out and the fastest growing populations were gonna be Spanish-speaking, and they were the only also populations where the average age was getting younger.
AR: So, despite gaps in the data, we do have a clear sense that there’s a significant need for spoken language services, with approximately 70,000 WNCians speaking from at least 70 different languages and, especially with Spanish, we’re likely to see those numbers grow over the next several generations. . .
However, spoken languages aren’t the only measure for gauging the size of language access needs in WNC. Let’s move on to our second group needing language services. .
AV: Language access is going to cover wide areas, you could have some that’s coming in that is hard of hearing, you could have someone that is blind and unable to access how to get around through the facility. . .
AR: Using census data, with all of its limitations, our team saw that the deaf or hard of hearing make up at least 2% of our entire population. . . with a higher concentration in Buncombe and McDowell Counties due to the Regional Centers for the Deaf and Hard of Hearing. . .
However, like with spoken languages, this is likely a conservative estimation, particularly as WNC is aging faster than the rest of the state. . . . Here’s Louise Noble, senior research associate with the NCCHW, who has worked on Healthy Aging projects statewide. .
LN: The WNC region has a 44% higher proportion of people aged 65 and older, its particularly important for this region to address some of these concerns. . .
AR: Concerns include many chronic conditions, but hearing loss and other physical challenges using language is certainly one of them.
The National Institutes on Health report that age-related hearing loss is one of the most common conditions affecting adults as we age with approximately 15% of American adults 18 and older reporting some trouble hearing, and about one in three people in the U.S. between the ages of 65 and 74 has hearing loss. Nearly half of adults older than 75 have difficulty hearing. Not only does WNC have a higher percentage of older adults than the rest of the state, the size of this population is also growing as the large post-WWII generation continues to age.. . .
LN: Yeah, so the boomer cohort, the baby boomers as they are sometimes called, has begun reaching that retirement age of 65, that threshold, right? And its creating stressors in multiple sectors because we don’t have the infrastructure to support them as they age,. . .
AR: In short, our identified community of the deaf and hard of hearing of all ages is roughly 20,000 people, but we’ll likely see that number grow reflecting the growing number of folks 65 and older here who will experience hearing loss.
There’s also a third group where we can use population data to measure the size of language access needs:
AV: You could have someone with limited reading ability, or they could be completely illiterate and how are you going to get those messages across? especially when so much of what goes on is like “here, fill out this form, you’re applying for this, or this consent form. . .”
AR: Literacy challenges actually make up the biggest language access needs group in WNC. A review of data collected by the Barbara Bush Foundation found that at least 18.7% of WNCians have below basic literacy abilities, which lead to a “host of issues that limit residents’ ability to access healthcare and lead healthy lives, . .”
Of course, this data also has limitations as these county-by-county estimations are from a survey from 2003, but as with census data, it serves as a baseline by which we can imagine the scope of language access needs here.
While literacy challenges may be significant in WNC, it turns out that health literacy, in particular, is an even bigger portion of population. The National Library of Medicine reports that 9/10 adults in the U.S. struggle with health literacy. This means difficulty with activities like “calculating the right dose of a medicine, following directions before a surgery, or checking a nutrition label to make sure an item is safe for someone with a food allergy.” So even for folks who speak the dominant language, are able to hear and see, and have basic literacy levels, there’s often still some sort of language barrier present.
To sum up, with at least 2% of WNCians deaf and hard of hearing, approx 7% preferring a language other than English, nearly 1/5th of the population with literacy challenges, and approximately 90% of us with health literacy challenges, language is a huge barrier to effective healthcare in WNC. While not everyone may need an interpreter, improving language access would improve health outcomes for most WNCians.
Luckily, when thinking about health policy and strategies, we’re not starting from scratch. . . After the break, we’ll hear some from each of our guests, as well as excerpts from several CHWs, about what they already see that’s working well to improve language access in the mountains.
BREAK
Hi everyone, Andrew here on the WNC HPI Podcast, the show that looks at public health strategies to improve health in WNC. We’ve been talking about language access as a tool to improve health outcomes with Aaron Viduarri of Buncombe County’s DHHS, Monse Ramirez from Cenzontle Language Justice Cooperative, and Rosalia McHattie of WIN.
Be sure to check our website at www.wnchealthpolicy.org for the transcript or to listen again. We’ll return to the conversation on language access in just a moment. . . .
That was Asheville-based Appalachian ballad singer Saro Lynch-Thomason humming the old shape note styled ballad Lady Margaret. You can learn more about her work and regional music traditions at sarosings.com. And now back to the show.
STRENGTHS
AR: So there’s a significant number of WNCians impacted by language barriers of different kinds. . . In this section, let’s hear some about what’s already going on in WNC to improve language access. Here’s co-founder of the Cenzontle Language Justice Cooperative, Monse Ramirez . .
MR:. Some of the things that have been working is that there’s been more consciousness or more education. . its more present and more organizations that have to scale up to meet the needs. . .
Just also, Cenzontle’s work has grown a lot. The network of national language justice workers has grown the movement for language justice, and it affects and kinda connects with a lot of the work that has been happening here locally.
AR: Ok, so advocacy for language access is growing and more people are learning about it and stepping up to provide it, particularly as more and more folks are asking for language services. . . . What do you see, Rosalia?
RM: In the last 5 years, language access has improved. . . Not only because we get more requests, but also because we have other competitors in the area. That is a good sign because for many years, it was very limited.
We also have an outreach person that is going to several facilities and she is taking not only information about WIN but also a better understanding of what Title VI is.
AR: Title VI, if you’ll remember, is part of the Civil Rights Act that mandates language access for federally funded entities. . .
RM: So, they are informed, and they know. . . and I think that is helping, you know, its helping the area.
Before, interpreters were just a few ones and facilities didn’t call interpreting services. For example, if you said you were bilingual, that was enough. I mean, they didn’t care. When you were at the appointment, if you didn’t get it, no one knew at the time. . but now it looks like they’re more into like “ok I need to make sure with these people is actually understanding what I’m saying and if I see that there is something missing, I will ask for an interpreter the next time.” So yes I think its improving, its getting better. . .
AR: Ok, so there’s more interpretation and translation services present than in some years past, with organizations like WIN, and of course, Cenzontle. . . and that greater education has made some providers more likely to offer interpretation. . .
RM: Nonprofit organizations are also advocating for this. And it shouldn’t be only about language I think it should be about different aspects.
AR: So you’re saying that when providing language access, we need to think about more than just interpretation. . . What different aspects apart of direct language interpretation do you think is important to add here?
RM: Like transportation- Hola Carolina does a great job about that. I think that’s how they started. And now they have more and more help for people. Centro Unido (CULA) in Marion does the same, they also work with pharmacies or food, And I think its Leicester, the Slavic community also has good service and good help to adjust to the new area for them. . . so, yes there are several nonprofit organizations that are helping the community in different aspects. .
AR: Ok, so also organizations working to improve folks’ social determinants of health, like food and transportation. . . .
We heard in Part 1, that actually those 2 organizations you mentioned, Centro Unido and Hola Carolina, are working on that in part by hiring CHWs. Let’s hear a little more from some regional CHWs and their clients about how CHW has been a support for language access:
Laura: So, for me, since I work with the Latino-Hispanic Community, I think. . . just the language is one way to connect. I speak Spanish, they speak Spanish, that's, you know, one of the main reasons why it's easy to connect. . .
Selene: Sí, habla español y yo puedo comunicarme con ella o sea yo puedo venir y decirle “necesito esto, ayúdame aquí” porque ella lo ha hecho. . . . Entonces por esa parte creo que sería mucha la diferencia.
Yes, she (my Community Health Worker) speaks Spanish, and I can communicate with her. . . that is, I can come and tell her “I need this, help me here” . . . because she has done it. . . So, in that way, I think it would be a big difference (between Community Health Workers and other providers). . .
Eleazar: Pues ha cambiado en una forma de que. . . como necesito unas medicinas y le hablo y ella me las trae, o en veces me ha ayudado, verdad? también a ir al doctor cuando (…) una emergencia. porque cuando me ha dicho que “venga inmediatamente,” ella me ha llevado. . . Me ha tratado muy bien, ella.
Well, it has changed in the way that. . . . as I need some medicine, and I talk with her and she brings it to me, or sometimes she’s helped me, right? Also to go to the doctor when (there was) an emergency. . because when the doctors told me “come immediately,” she took me there. She has treated me very well.
Laura: . . I think it's just building trust. . . just being consistent with the clients it's really important. And just really keeping that connection with the community, with having outdoor events where we can talk to them. . .
Rachel: We’re able to set up a tent and we can do blood pressure, blood sugar readings, and we also write ‘em down for them and we give them information about the clinic. . . if they don’t have a provider or a clinic they go to, we can give them that information. . . and it also helps to someone who may not know they have high blood pressure, someone that don’t know they have sugar. . . this is a way for us to help them to find out about it. . . . And at these events, we talk to them about that. .
Laura: or we go to the businesses and we talk to the owners.
Rosendo: . Era donde la gente me podía localizar donde yo podía entregar mi información, donde yo podía. . . la gente si quería a algún necesidad que tuviera. . . ya sea social, ya sea de alimento, ya sea de salud, pues ahí preguntaban. . .
That’s where people could locate me, where I could give out information, where I could. . . . the people, if they wanted. . . for some need that they had. . . . Whether it be social, whether it be food, whether it be health, well, there they asked. . .
Laura: We deliver flyers and everything also in a language that the community can understand. . . because for us, we work with a lot of community that had to immigrate here to this country before they could finish school, and they didn't have opportunities of education. . . Also, the way that you communicate to the community is really important. That was one of the things that really was crucial for when I started as a CHW. . because during COVID, all the info that was out there that was putting by the CDC or other organizations, the Spanish level was really high, and our community was really confused - they didn't understand what it was saying. And having somebody that can talk to you in a plain language, that knows your culture a little bit- that made a big difference.
Selene: y hay personas que hablan español pero te dicen “habla breve con palabras cortas y claras. . . ” como “ve directo a lo que quieres decir” y como con ella (mi promotor de salud) no, porque tú puedes hablar, o sea. . . yo sé que ella me va a entender
and there are people who speak Spanish, but they tell you “be brief with short and clear words. . . " like, ‘get to the point’ with what you want to say. . . and like, with my CHW, no. Because you can talk. . I mean. . . I know that she is going to understand me.
Linda: entonces diríamos que la diferencia sería esa, no? que ellos son bilingües y que pueden apelar a tus sentimientos, porque hay personas que aunque son bilingües y te están interpretando- ese es su trabajo. . . y ellos no sienten lo que tú estás sintiendo. Ellos solamente dicen, repiten. y es todo
So, we would say that the difference would be that then no? That they are bilingual and that they can invoke your feelings. . . because there are people who although they’re bilingual and they are interpreting, it is their job. . . and they don’t feel what you are feeling. They just speak, repeat, and that's it. .
Laura: We’re that trust piece right between a lot of the resources- specially the health systems. . . and the communities. . . there's a lot of fear in the community still to go to the doctor - especially Hispanic/Latino Community because of the language, because they don't know their culture, and they don't have access sometimes to health insurance so they don't even want to try to go to the doctor because they cannot afford bills. . . so having the CHW who knows how the health system works, and where are the barriers of the community, and being that bridge, I think that's what makes us special,
Refugio: Nuestra focos o nuestra esencia es construir un puente entre culturas. . . porque nosotros no somos una clínica. . . pasamos todos los recursos lo que lo llevo en recursos de la pandemia los pasamos a la comunidad. . .
La aportación a mi trabajo, licencia, es referir la gente a donde estén los recursos, y darle seguimiento. . . cuando le digo este “¿Qué pasó? ¿ya recibiste la atención? ¿necesitas algo?” o sea. . ese es mi función: referir. . . yo no puedo. . . Yo no vacuno ¿eh?
Our focus, or our essence, is to build a bridge between cultures. . . because we are not a clinic.. . We pass on all of the resources. . . The resources we received during the pandemic, we passed to the community.
My role is to refer people to where the resources are, and to follow up. . . When I say, “What happened? Have you received attention yet? Do you need something?" I mean. . that’s my function: to refer out. . . I can’t. . . don’t vaccinate anybody. . .
You’re listening to the WNC HPI Podcast. Today’s topic is language access. We just heard from several CHWs across WNC and a few of their clients characterize how CH Work is a strength to language access. . . whether it’s through spoken language, code-switching with providers, built trust, or other means. These clips were taken from the 2023 CHW Chronic Disease Initiative Evaluation, completed by one of the key partners of the HPI, the NCCHW with support from MAHEC and the Dogwood Health Trust. You can learn more about that project by checking out their website, linked on the transcript online at www.wnchealthpolicy.org. . . It should be noted that the English voiceovers were completed with amateur translations, and while we feel confident in the general sentiments, there could be some inaccuracies in tone and word choice.
As CHWs are bridging clients across different organizations, I’m reminded of a strength mentioned a lot in public health in WNC: the collaborations between organizations. Monse, as part of a language justice cooperative, have you seen examples of language access collaborations in our region?
MR: Yes, the collaborative that NC has been working on with different county governments, the Building Integrated Communities (BIC) collaborative and the Language Access Collaborative. . .that has been something that is so amazing that is happening. Its been able to provide training and knowledge to different government folks and counties in NC. That’s huge. That hasn’t ever happened before. But like, for a lot of the time, Cenzontle and language justice advocates would get together and figure out how to get moms to organize in their schools, and also how to provide more interpretation for different events, or like, meetings that involve the community. And now, like, people are doing that with their local governments and their counties. That's huge.
AR: Ok, so currently, there’s two bigger collaboratives working with some county governments on language access. . . but yall have also connected folks in a grassroots way for language access and also gotten some movement forward with local governments. Could you describe what that kind of collaboration has looked like?
MR: During the pandemic we did get hired by Buncombe County HHS to cover the Spanish interpretation and all the updates that they were doing and live streaming. We did work to get that information, figure out ways to cover those remotely. And we had to figure out how to use zoom and have in-person meetings and have it be hybrid. So we definitely worked together to figure those out and have them be available in both English and Spanish. I got to interpret some of them, and we would be able to see how many people were listening in, and it was quite a few people, so they were able to get that information out to people who otherwise wouldn't have had access to that information because it was only available in English. So definitely that was one of the times that we were able to collaborate.
AR: As we heard in the beginning, Spanish, Russian, Ukrainian, and in some areas, Vietnamese, are probably the biggest language groups outside of English in WNC, and so having pandemic info in those languages would be critical to reduce the spread. I wonder if you see language justice movement also growing with less visible language groups that might not have the same population size . . .
MR: Yes. There's also been more and more indigenous language revitalization work. There's a group here in Asheville called Mä Hñäkihu, that is, working with people who speak the Hñähñu language and teaching that to the younger generations and building spaces of practice and cultural celebration. So, there's a lot happening here -I feel like WNC has so many languages, but yeah, there's a lot of beautiful work and a lot of movement that has come out of the work here.
AR: I was reminded that JMPRO Community Media has several community journalists who offer news and events in the languages Mam and K’iche, along with Spanish. Probably one of very few media groups in the U.S. to offer that.
Also, I remember Casey Cooper, the CEO of the Cherokee Indian Hospital of the Eastern Band in Cherokee County, describing how the Cherokee language was built into the infrastructure of the hospital, consulting with elders about how to describe elements of the building that may not have had a direct translation. . words like Emergency Room. . . so those seem like some pretty unique strengths here for language access. . .
So as a region overall, strengths have been increased awareness of language access needs, an increase in groups offering interpretation and translation services, CHWs supporting multilingual communities through their organizations, some local govt partnerships, and some organizing around indigenous languages like we just talked about. I think another important strength too is that one of the 18 counties has a language access coordinator on staff and how that offers a model regionally. . Shifting to that and the specific strengths for language access practice, let’s hear about what has worked well in language access coordination in Buncombe County’s DHHS at an organizational level to give a sense about what kinds of examples can be offered for other organizations in the region.
AV: So some of the things that have been working for us within HHS, we try to have a multilayered approach because its not always gonna be a situation where you have an interpreter on site. So, within HHS and our language access team we have three medically certified interpreters for Spanish and one for Russian and we can assist in those languages when available. So outside of that, we have bilingual staff that are tested in general communication, and they can provide services directly in that language. They are not to be used as interpreters or be put in situations outside their area- they’re just providing direct services.
We still can’t cover all languages so that’s when we have our multilanguage partners that we have contracts with, and that would be your over-the-phone interpretation or scheduling in person, or now there’s more use of the video remote. . . but just making sure we have the documents translated - we try and hit our core languages of Spanish and Russian when we can, and for the other languages, we either offer the interpreters to read over the forms, or depending on the situation and need, we can see about getting that translated into the language.
One of the things I’ve done for HHS is when we receive our invoices from our over-the-phone companies, I’ll go through each invoice and ill break it down per department and language served so I can see if there’s a spike and then I can try to plan accordingly to try to get more resources around that language.
AR: So, I’m hearing that organizationally, having a multilayered approach is really important, and that the Buncombe County DHHS is one local example of how that can look.
We’ll hear more from Aaron about strategies that different organizations can use in Part 3 of this series, but I’d like to highlight here that even having a section of government that is actively looking at improving language access is a strength, when the norm is such limited service..
Having heard a little bit about what’s working, we’ll move on to the challenges we’re experiencing as a region for language access. First, we’ll go back to the CHWs, and then touch base again with Aaron, Monse, and Rosalia. After the break. . . .
BREAK
Hi everyone, Andrew here on the WNC HPI Podcast, the show that looks at public health strategies to improve health in WNC. We’ve been talking about language access as a tool to improve health outcomes with Aaron Viduarri of Buncombe County’s DHHS, Monse Ramirez from Cenzontle Language Justice Cooperative, and Rosalia McHattie of WIN.
Be sure to check our website at www.wnchealthpolicy.org for the transcript or to listen again. We’ll return to the conversation on language access in just a moment. . . .
That was Asheville-based Appalachian ballad singer Saro Lynch-Thomason humming the old shape note styled ballad ‘Evening Shade.’ You can learn more about her work and regional music traditions at sarosings.com. And now back to the show:
CHALLENGES
Understanding that we’re not starting from scratch with strategies to improve language access, lets now look at some of the persistent challenges here. To do that, we’ll listen to excerpts from interviews with some of our regional CHWs and their clients, recorded by the NCCHW’s Culture of Results Team. While these interviews weren’t explicitly about language access, its impact emerged as a theme facing many community members.
Laura: There’s a lot of patients that have a lot of needs I think that are not getting solved just because of that- the language barrier, the cultural barrier. . . that the medical providers dont understand. ..
Refugio: y me di cuenta de que las personas como yo, que no teníamos el segundo idioma inglés, tenemos muchos problemas para comunicarnos. .
and I realized that people like me, who don’t speak the second language English, we have a lot of problems in communicating. . .
Lotta: I also feel like that that kind of is a barrier, the communication, of not being able to speak with the Hispanic community. That’s something that I personally would like to know more. I mean, if I could take Spanish, you know, and learn the language and be able to communicate better with them, that would be great.
Eleazar: Pero como no hablo bien el inglés, la americana me dice “que necesita?” y yo no puedo ya explicarle que lo. . que necesito ¿verdad? Y allí en el doctor, él nunca ha puesto un intérprete. Donde voy. Nunca había un intérprete. . . En el otro si, y en el hospital, si. Pero en eso, no.
But since I don't speak English well, the American woman tells me “what do you need?” and I can’t explain to her what I need, right? And there at the doctor, he has never called in an interpreter. The one where I go. There was never an interpreter. In the other, yes, and at the hospital, yes. But at that doctor’s office? no.
Selene: Pero sí, ha sido un poco difícil por el idioma. Eso sí. El idioma, eh. Antes no había este.. . muchas personas que interpretaran. Y este ya era más difícil. Yo no sabía que aquí este podría ayudarme.
But yes, it has been a bit difficult because of the language. Yes indeed. The language.. . Before there wasn’t this. . . . many people that will interpret. And so, life was that much more difficult. I didn’t know that there was anyone who could help me.
Linda: Cuando interpretan por las pantallas. . . yo no soy cien por ciento bilingüe, estoy aprendiendo el inglés, pero cuando yo he visto, cuando me han interpretaron a mi, ellos no dicen lo que yo di. Porque estoy aprendiendo y digo “yo no dije eso” pero no quiero ser grosera y decirle. . .
When they interpret with the screens. . . I’m not 100% bilingual, I’m learning English, but when I’ve seen it. . . when they were interpreting for me, they didn’t say what I had said. . .Because I am learning and I say, “I didn’t say that!” But I don’t want to be rude and tell them. .
Laura: Eso lo han dicho mucha gente también.
This is what a lot of people say as well
Linda: Pero eso, eso lo que está pasando con las pantallas. . .
But that, that’s what’s happening with the screens. .
Laura: Es muy malo.
It’s very bad
Somebody told me a story that there was a man who passed here in the hospital, who had COVID. . and he didn't find out he had COVID until the very last days when they had to intubate him. . . . And they were using the screens and he couldn't really understand anything, so he didn't even understand why he was there. . . And he was alone in a room for, like, two weeks, and not until the last day that he was able to talk to somebody. I think it was somebody from another organization here in Marion who speaks Spanish. And they told him, like, yeah, you have COVID, and we're needing to intubate. And he didn't know, and he ended up passing. So just stories like that are like. . . that's unbelievable. . . .
Rosendo: entonces hay tanta necesidad.. . y necesidades crecientes, porque yo sé lo estoy diciendo: la población, la comunidad latina está creciendo y cada vez con muchas barreras como ser la falta de seguros médicos, la falta de idioma, del lenguaje. . .
So there’s a lot of need.. . and these are growing needs because I know what I’m saying: the population, the Latino community is growing and each time with many barriers like a lack of insurance, the lack of language. . .
Laura: Since I’m working with the Hispanic/Latino community, if you are looking for a resource that is offered in English you know, for English-speaking, its right there, always. You will find it. But if you have to find something for the Spanish (speaking) community, just because of the language, you don’t find it, or you have to do like extra work or look so much more to find that same resource.
For like Hispanic/Latino, a lot of times, they go to the doctor’s office, and they will be telling them things and just for respect they will say yes like they are understanding but they are not really understanding and they’ll be afraid to ask, exactly. .
Eleazar: por ejemplo, es que se da la confianza. . . y ella me da mucha confianza ¿verdad? Mucha confianza y si divina me perdona, no me dan esa confianza, yo no me voy a atrever a decir ni nada ni a pedirle nada porque uno no tiene esa confianza que ¿si me explico? Y eso es lo que pasa. Cuando hay confianza uno habla. . . como dijo usted. . . de las necesidades que uno tiene. . . verdad? Ella me ha dado mucha confianza y yo yo no me da pena ni vergüenza decirle a ella. . sabe que necesito unas pastillas o ir al doctor. . . ¿si me explicó? y no todas las tengo la misma la confianza de decirles, verdad?
for example, it’s that trust is given. . and she gives me a lot of confidence, right? A lot of trust. . . and you’ll have to forgive me, others (other healthcare workers) don't give me that trust; I’m not going to dare say anything or ask for anything because there isn’t that trust, does that make sense? And that's what happens. When there is trust, one talks. . . like you said. . . about the needs one has, right? She has given me a lot of confidence so that I am not ashamed or embarrassed to tell her. She knows that I need some pills or to go to the doctor. . . know what I mean? And not everyone has the same confidence to tell them, right?.
Richard: that's when I really seen the need. . . how many people were really not. . . aware of the resources that they can receive. They really hadn't had regular checkups and, you know, really been to the doctors and stuff, because it's not culturally the thing to do.
Laura: Just not having that understanding of the culture is a big barrier.
Alex: I mean, even people who speak English are afraid to ask those questions.
Jacque: Yeah, sure
Laura: I think that happens to anyone. . .
Alex: But if you have that language barrier it’s even more intimidating.
Laura: Because sometimes it’s that attitude that the providers have. . .
Rachel: I’ve had clients who couldn’t read and the provider will say “I don’t understand why they aren’t taking their medicine!” Well, if they can’t read what their medicine says on it, how are they gonna do that? And a lot of times people are just ashamed and won’t tell somebody. You know? They’re not gonna tell a doctor “I cant read that. . “
AR: Those were excerpts from some CHWs and their clients here in WNC, from the NCCHW’s recent evaluation of the work they do. While language access wasn’t the focus of the interviews, it was a regular theme, with crossovers into workforce shortages, needed training, inaccurate interpretation, literacy challenges, and mistrust. To learn more about CHWs, you can check out the 2023 CHW Chronic Disease Initiative on the NCCHW’s website, you can also visit the NCCHWA website, and stay tuned to future HPI podcasts where we’ll hear more about CHWork later this year. Speaking of language access challenges, it should be noted that the English voiceovers were completed with amateur translations, and while we feel confident in the general sentiments, there could be some inaccuracies in tone and word choice.
Let’s bring it back to our 3 guests: Monse, Rosalia, and Aaron. Monse, what particular challenges do you see for language access in WNC?
MR: Yeah, I would say, like one of the biggest things is people just never have had to think about this in their own lives. A lot of English speakers exist in this English-speaking world and have never had to think about, “Oh, what would it be like if I was in a place where I didn't have access to the language that's being spoken?” So, a lot of the time people just don’t know what they don’t know. . . It's like the lack of awareness, lack of experience to be navigating a world that won't cater to your needs.
Also, there is xenophobia; people are afraid of or don't know how to accommodate. . . or feel people should be speaking English if they are in this country.
I would say too, there's like a lack of both relationship building, but also even engaging people and communities and trying to kinda think outside of the box of what organizations are used to doing. I was recently interpreting for one of the Language Access Collaborative meetings, and there was this beautiful panel where local organizations who do work with immigrant, with refugees, and one of the questions was about, “how can the local governments, work and do better to connect with immigrant and refugee communities?” And one of the panelists said that a lot of the times people are literally fleeing and running away from their countries because of their government, and the lack of trust or fear about their government. And they come here to the U.S. and probably aren't gonna trust the government because of their lived experiences. So, a lot of the ways that organizations do outreach is not gonna hit that population because of people's lived experiences, because of the lack of trust, because of the trauma that people have faced. So it's not just gonna be like, “okay, I'm gonna post it on on Facebook, or I'm gonna post it on our church’s bulletin board,” because the people that are you're trying to bring in, that you're trying to connect with, that really do need access to these resources, are not gonna go look at that bulletin board or not gonna go to that website in order to get that information.
AR: So some of the things that are challenges to language access here include a lack of awareness, notable fear or dislike of people from folks from outside of the US, and ineffective outreach to different language groups by many regional organizations. . .
MR: I would say, too, there's lack of knowledge around funding and resources to fund translation services or interpretation services, or even to pay bilingual staff people a higher wage, and a lot of the times bilingual people end up doing this work for free, which can be really tiring, and not something that they should have to hold because of the lack of planning or resources available through their organizations.
AR: Ok, so organizations are missing opportunities to get language access resources, and even when there are bilingual staff on hand, organizational failure to make a language access plan leads to staff doing unpaid labor that may be outside their job description. . . of course, as we’ve heard at various points, many organizations either aren’t hiring or aren’t using staff with language skills. . . Here’s Rosalia again:
RM: We all know that interpreter services should be available for any encounter. . . unfortunately, that’s not reality because of lack of interpreters or maybe the lack of information in the facility. It should be followed, it should be respected, but it’s not happening. Even though its improving, as I was saying, but there are still places where they’d rather not receive that patient and say, “you know, we cannot provide services here you need to look for other facility.” It happens.
AR: So getting compliance with the Title VI law has been a challenge here. . and hardly been made a priority in many organizations. You also mentioned a lack of interpreters. A workforce shortage has been a regular theme for healthcare in NC. Aaron, as a healthcare facility that already understands the need for language access, what kinds of challenges do you see in maintaining that workforce at the DHHS?
AV: Challenges can be finding and maintaining bilingual staff that are qualified in those positions. It’s expensive to live around here so opportunities come up and they’re going to move on, so staffing is always difficult. . .
AR: And without the staff, there’s no healthcare. So there’s the challenge in healthcare facilities prioritizing language access and then the challenge of finding or appropriately training folks and compensating them sufficiently. . .
RM: Yes. there is a need for that. Not only for healthcare but also for mental health. And for those type of interpreting sessions, we try to find somebody that is prepared for this because it is very challenging. . . So yes, there is a need for that as well. . .
AR: And it sounds like a need for support for interpreters too, no? Does that also contribute to workforce burnout?
RM: That is something, you know. Usually, when I talk with interpreters and ask about this, they only say, “well yes you know this is what we do this is our job and what we try to do is just. . . once we leave that place we need to focus on something else, and change,” but, you know, ive been in that situation once and its not so easy, because you want it or not, there is a connection and you as a human, you will feel for that person. Let’s say you’re interpreting for something legal, immigration, I remember family members were separated because of immigration issues. .
I remember one or two sessions with family members were really really in bad shape because of this. . that is shocking, I mean, and it was hard for me to just try to forget about that situation, especially if you see someone crying, a child. You know, that is really sad, it can break you inside. .
AR: So language access challenges include how awful the social and political landscape can be for people folks who don’t speak English, speak English as a second language, or are seen as outsiders, whether from language barriers or not. . . and then, if the interpreter is maybe one of few folks on the healthcare team who the patient can relate to, that puts a lot of pressure on the interpreters and that could make that workforce shortage even more intense. . .
In Part 1, we talked some about the differences between bilingual staff, interpreters and interpreters with medical certification and the expressed need of having medical certification for interpreters in the doctor’s office. Of the interpreters that are out there, why aren’t there enough who have medical certification?
AV: One of the big challenges can be the fact that there’s not like “hey, here’s this one testing you’ve gotta have this, there’s a law.” But even then, you’ll still run into this person may not have that degree but they’ve been interpreting for years so then they have like 20 years of experience of interpreting where its gone really well. . . But yeah, certification is tricky cause there’s not one standard way of being certified.
RM: It's a very big challenge actually, because, to start with, its not easy to find a place to study to become an interpreter and if you find something, its kind of expensive.
AR: Ok, so with folks interested in joining the interpreter workforce, there aren’t always accessible paths to becoming a certified medical interpreter, because there are few places offering them or due to cost. . . and then you don’t always know what you’re gonna get with the training courses that do exist. . .
AV: And then we’ve also got the constantly changing language needs in the community. There could be influxes where we get refugees or immigrants from certain areas depending on what’s going on in the world. And I feel, anything that can cause an influx of people, there could be droughts or famine or war. . . anything can happen anywhere in the world where all of a sudden you’re going to see a spike and it might be a language you already have in the community, or it could be something completely new where you have no resources whatsoever and you’re starting from scratch. And that can be challenging.
AR: So not only is it hard to get your organization on board with the language access plan and secure a workforce that has all the appropriate trainings for the languages you have, but a challenge is being flexible to those changing needs! . . I’m thinking how WNC has recently housed refugees fleeing Afghanistan following the U.S.’s role there, as well as the Ukraine, and different indigenous communities from Mexico and Central America. . . while there’s already a community of Ukrainians here, there isn’t that linguistic infrastructure for Dari and Pashto from Afghanistan, or Mam and K’iche from Guatemala. . .
Thinking back on how this show started, that reminds me of how hard getting data on what those needs even are can be. . .
AV: getting accurate, current data is always difficult and its going to depend in the field that you are and kinda what the platform that you are using, cause maybe you’re really good at capturing the data for the language when your patient or your client is in office for a visit but if people are calling in just to check for help maybe that’s not being logged, so maybe we could be missing opportunities to help there. Especially if your organization is large youll find that there might be areas where the language data is captured and is fairly accurate, but then theres huge swaths of it where its no man’s land.
And also the lack of WIFI and cell service through some of the further regions. Especially like if you’re going out to do field work to visit the patient directly. So you might have to have an in person interpreter in that situation because you can’t access it over the phone or you can’t do a video remote interpreter. That’s a challenge, so when that situation comes up, it kinda ties into the other challenge which is budget- “how do you fund all these services to make sure that we can provide these great and equitable services, regardless of the language that’s spoken?”
So there’s a range of challenges for WNC when it comes to language access: Awareness, outreach, mistrust, fear, budgets, legal compliance, workforce, technological infrastructure, and good data, and of course all of these things lead to limited or poor quality healthcare.
Despite all of these challenges, though, as we heard earlier in the show, there’s also a lot working for us here too, including a rich linguistic landscape, a growing awareness of language access needs, strong collaborations, passionate language access workers, and a local of example of how language access plans could play out in a county govt. In the next installment, we’ll look at what strategies our region can use move forward to advance health access through language as well as some resources recommended by our three guests. In the meantime, be sure to check out Part 1, the transcripts, and some of the subjects explored today.
OUTRO
AR: You've been listening to the WNC Health Policy Initiative Podcast through the NC Center for Health and Wellness at UNCA. To listen again or learn more about public health issues in WNC, check out the website @ wnchealthpolicy.org. To find some of the resources mentioned in this show about language access, head to the blog section at the top of the website where you’ll find additional show notes.
If there’s a WNC health issue that you’d like to hear more about, speak about, or comments about anything you’ve heard on an HPI podcast, feel free to send us an email at info@wnchealthpolicy.org.
A big thanks to the AshevilleFM Studios where this installment was recorded.
Another big thanks to Asheville-based Appalachian ballad singer Saro Lynch-Thomason for humming the old shape note styled ballad Lady Margaret and Evening Shade in the mid show break. You can learn more about her work and regional music traditions at sarosings.com.
English language voiceover work was provided by David Schensted, Chichi Alcazar, and Coco Rainey-Alcazar.
To find more information about CHWs, see the North Carolina Center for Health & Wellness’s 2023 Community Health Worker Evaluation, as well as the North Carolina Community Health Worker Association’s website.
Other music included in the podcast includes old ballad, Little Margaret, performed on banjo by Cath and Phil Tyler. Found on the FreeMusicArchive, it is licensed under an Attribution- Noncommercial-Share Alike 3.0 United States License.
Additional music includes the tracks Some Nights End, The Silver Hatch, Lover’s Leap, O Holy Still, Talens Bal, Great is the Contessa, Night Music & Night Watch by the Blue Dot Sessions; These tracks are found on the FreeMusicArchive under license attribution international CC BY 4.0.
Be sure to check the website for more HPI podcast episodes and other resources @ wnchealthpolicy.org. Thanks for listening.
