Access to appropriate interpretation is essential for the health of children

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Language demographics in Canada

The latest Canadian census demonstrated the significant diversity of languages in Canada^[1]. Twenty percent of Canadians (6.8 million people) reported using a mother tongue other than English or French, and 6.2% of Canadians (2 million people) spoke a language other than English or French as their sole home language^[1]. In Canadian health care settings, the potential for language discordance—where a health professional and patient are not proficient in the same language—is high^[2].

What trained interpreters do

While translators work with written language, interpreters facilitate oral communication between people who are not proficient in the same language. Interpreters are typically working between two languages in both directions, in real time. Translators, on the other hand, are usually specialized in adapting text from one language to another, with opportunities for review and revision. More details about the role of an interpreter, how to find and appropriately use an interpreter, and the skills and qualities to look for are described on Caring for Kids New to Canada, a resource for health professionals serving immigrant and refugee children, youth, and families^[3]. Health professionals who use interpreters should also familiarize themselves with the principles of cultural competence and cross-cultural communication^[4][5].

Trained interpretation can be done in person, or via video or telephone. The literature does not clearly demonstrate whether one form is better than the other^[6][7], and a health professional’s choice will depend upon availability, logistics, cost, language, and the clinical picture or setting. With technological advances, there are now many different platforms that are portable and can interpret many languages and dialects. Using trained interpreters, either in person or by video or telephone, helps address the Canadian health care system’s principles of equal access, health equity, and universality^[8].

Language discordance and health

In Canada, poor proficiency in English or French is significantly related to self-reported poor health^[9]. When a physician and patient cannot adequately communicate, potential harms include poor clinical outcomes^[10]-[12] and readmission to hospital^[13]. 

A systematic review of the literature has demonstrated the benefits of using professionals over so-called ‘ad hoc’ interpreters—people without training, such as family members or bilingual staff^[14]. The use of professional interpreters was associated with improved communication, health care use, clinical outcomes, and satisfaction with care^[14]. A small amount of literature has suggested that the use of professional interpreters in paediatric health care settings is low^[15][16]. No reports of professional interpreter use in medical interactions in Canada have been published, but expert opinion suggests it is low. 

In a one-time survey by the Canadian Paediatric Surveillance Program (CPSP) that looked at access to and use of interpretative services for Syrian refugees, 87% of the clinicians who responded had access to interpretative services and only 67% of those interpreters were professionally trained (20% were trained non-professionally and 13% were friends and family members)^[17]. The Canadian Paediatric Society^[3], American Academy of Pediatrics^[18], and the Canadian Medical Protective Association^[19] have recognized the importance of interpretation and provide guidance for health professionals. The National Newcomer Navigation Network (N4), in consultation with health care and settlement providers across Canada, has published a position paper recommending a national standard for health care interpretation. This paper also makes recommendations on how to address language barriers for newcomers^[20].

Potential harms associated with untrained interpreters

The use of untrained or ad-hoc interpreters has been shown to increase errors of omission, substitution, editorialization, and addition^[21]. When a family member acts as an interpreter, trust and confidentiality concerns also arise, along with potential for the interpreter to play a protective role or avoid conflict. Any of these issues can increase opportunities for medical error and misunderstanding. 

When treating adolescents, health professionals must navigate issues of confidentiality and consent to treatment^[22]. Using a family member or an untrained stranger to interpret on behalf of a vulnerable adolescent makes it difficult for a health professional to respect and maintain the patient’s autonomy and confidentiality.

Why children should not be used as interpreters

Children and youth are not sufficiently developmentally mature to act as interpreters in health care. Using children and youth as interpreters in health care settings places them in an inappropriate and potentially difficult situation that may have lasting negative effects on both their own mental health and their relationships with other family members^[23].

Asking a child to serve as an interpreter for a family member can:

• lead to stress^[24],
• place a child in the role of a parent^[25],
• cause poor psychological health^[26],
• cause parent-child conflict^[27],
• expose a child to disturbing information and unfairly burden them with family secrets^[27],
• cause a child to miss time from school^[28].

If a negotiation or debate occurs, a young person may be forced to play the role of 'broker', with loyalties divided between a health professional and the family. Using children and youth as interpreters also increases the potential for miscommunication between the physician and the family, which may lead to medical errors, inappropriate treatments, and emergency room visits^[22]. The evidence suggests that health care providers are insufficiently aware of the negative effects of using children or youth to interpret for family members^[28].

Recommendations

1. Trained face-to-face interpreters, video, or telephone interpretation should be available in hospitals and other health care settings where patients and physicians are not proficient in the same language.
2. Children and youth should not be used as interpreters in health care settings.
3. Interpretation services should be part of hospital accreditation standards. Organizations that represent health professionals, and agencies responsible for accreditation should work with the interpretation community to develop and implement a national standard for interpretive services.
4. Establishing free 24-hour interpretation services should be a priority for all provinces and territories.

Acknowledgements

This position statement was reviewed by the Canadian Paediatric Society’s Global Child and Youth Health Section Executive, and by the CPS Adolescent Health, First Nations, Inuit and Métis Health, and Mental Health and Developmental Disabilities Committees.

CANADIAN PAEDIATRIC SOCIETY CARING FOR KIDS NEW TO CANADA TASK FORCE (September 2022)

Members: Charles Hui, MD (Chair); Tony Barozzino, MD; Stacey A Bélanger, MD PhD; Mahli Brindamour, MD; Muna Chowdhury, MD, College of Family Physicians of Canada; Susan Kuhn, MD; Sayo Olatunde, MD, College of Family Physicians of Canada; Radhika Shankar, MD, CPS Residents Section; Shazeen Suleman, MD

Principal author: Charles Hui, MD

References

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.