Background

Migration has increased rapidly over the last 15 years.1 Between 1990 and 2013, migration rose worldwide by over 77 million (50%), with most growth occurring between 2000 and 2010.2 In 2015 there were 244 million international migrants, with the largest number of migrants residing in the United States.1 Migrants have been defined as individuals who make a choice to live in another country, without any coercive external factors.3 In comparison, a refugee is a person who is living in a country not of their birth and is unable to return to their country of origin for fear of persecution.3 The United States, Australia and Canada, predominately English speaking countries, are among the most active refugee resettlement countries in the developed world recently accepting refugees from Syria, Myanmar, Iraq, Somalia and the Democratic Republic of Congo.1 Increased migration in the last decade has seen a rise in the number of people with low English proficiency (LEP) living in countries where English is an official language. Someone with LEP refers to any person who self-reports that their spoken English is less than "very well".4 This implies that their understanding of spoken and written English is also limited. In 2011, the US Bureau of Statistics reported 21% of the population aged five and over spoke a language other than English at home with similar percentages reported in Australia (18%).5

Migrants and refugee families with LEP are vulnerable during hospitalization. Safe medical care relies on a clear exchange of information between healthcare providers and patients, parents and carers.6 Several systematic reviews have reported that patients with LEP faced barriers in communication of information, which led to gaps in service provision and impeded safe care.7-9 Primary studies have also shown that communication barriers can limit LEP patients' access to health care,10-12 and result in inadequate understanding of diagnoses,13 poor adherence to treatment, reduced healthcare follow-up, medication errors11,13,14 and other adverse events.15 Patients with LEP have reported less satisfaction with care,11,16,17 lower quality care and less willingness to return to hospital following care compared with English-speaking patients.11,14,16,17

In pediatric settings, the healthcare provider communicates and establishes a relationship not only with the child patient but also with the parents or primary caregivers.6 Healthcare providers aim to work collaboratively with the family, including the child and parents or primary care givers, sharing complete, honest and unbiased information.18 This relationship is harder to establish when communication is with families with LEP. Primary studies have shown that an inadequate relationship between families with LEP and healthcare providers in the hospital setting have resulted in more frequent emergency department presentations,19 increased admissions to hospital following triage and children admitted with higher acuity.20 Compared with English-speaking patients, pediatric patients from LEP families have been reported as having increased diagnostic testing within emergency departments, which have resulted in increased resource utilization19,21 and increased length of hospital stay.22

A key strategy to facilitate effective communication between LEP migrant and refugee children and families and healthcare providers is the use of professional interpreters. Interpreters translate verbally between people who speak different languages. In a healthcare setting, the professional interpreter will translate for the healthcare provider and the patient and family. Professional interpreters have skills and experience that are assessed and they are accredited by a professional body.23 Qualified and medical interpreters are also accredited interpreters, therefore, the term professional interpreter will be used throughout this systematic review and incorporates all interpreters who have met prerequisite standards in their country. The standard that has been set for working as a professional interpreter contrasts with an ad hoc interpreter, a family member or friend interpreting for a patient, a bilingual person, a staff member or a person in the area who volunteers to interpret.24 Importantly, the use of ad hoc interpreters, involving staff and family members, including children, has been shown to impede effective communication between migrant families with LEP and healthcare providers.7,8,25,26Ad hoc or untrained interpreters are also more likely to make errors, misinterpret or omit information, ignore embarrassing issues and provide low-quality communication.11,26 Enabling people to communicate in their own language through the conduit of professional interpreters has also been purported to build a healthcare provider-patient relationship based on respect, trust and cultural safety.8,27 This highlights the importance of using professional interpreters to assist with communication between LEP families and healthcare providers.

Barriers to the use of professional interpreters have been reported and include lack of staff training, cost, context, availability, resources and correct matching of interpreter to job specification.28,29 Time constraints, sensitivity of health concerns, gender mismatch and/or staff non-familiarity with interpreter processes have negatively impacted on professional interpreter utilization and effectiveness.26 Further, in the acquisition of English as a second language, it takes time to develop competency and fluency6,30 both of which are required for the person to become English proficient. It is estimated that an adult requires five to eight years to become English proficient, which has implications for medical care.30 Healthcare providers require clarity regarding their role and available health services when caring for families who have not attained this proficiency. Additionally, health information including discharge instructions needs to be modified for migrant and refugee families with LEP.27 Understanding the family's language preference, fluency in English and their need for a professional interpreter will allow healthcare providers to be better equipped to provide safe care.6,31 Despite the barriers to the use of professional interpreters, primary studies have reported the impact professional interpreters have on hospitalized children's outcomes, medication errors and satisfaction with hospitalization.32-34 Professional interpreters provide a vital link between healthcare providers and migrant patients with LEP to attain safe care and the best outcomes for children.

Preliminary sources searches for systematic reviews on the impact of interpreters on health outcomes included the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, CINAHL and ProQuest. Previous systematic reviews have included the impact of professional interpreters on the quality of health care,8 quality of psychiatric care9 and improving clinical care for LEP adult patients.7 However no recent systematic review was found that identified, assessed and synthesized the evidence of the impact of professional interpreters on outcomes of hospitalized children from migrant and refugee families with LEP. As there are studies that have reported on the impact of interpreter use on children's outcomes,20,22,33-35 it is timely to synthesize this evidence. A systematic review synthesizing research on the impact of interpreters on children's outcomes will inform healthcare providers and policymakers in English-speaking countries whether the use of professional interpreters impacts on outcomes for migrant and refugee children and families with LEP relating to safety, satisfaction and period of hospitalization. Given the increasing migration of people with LEP to countries such as the United States, Canada and Australia, it is timely to synthesize this research.

Inclusion criteria

Types of participants

The review will consider studies that include LEP migrant, refugee or asylum seeker families and children aged 0-18 years born outside the country in which they are now residing where English is the principal language. The children must have received or be receiving in-patient, outpatient or ambulatory hospital care. Families will include parents, primary care givers and extended family.

Types of intervention(s)

The review will consider studies that evaluate, but are not limited to the following: use of professional interpreters (medical, qualified), and modes of delivery of interpreter use (onsite face to face, phone and teleconference). All durations and frequencies of interpreter use will be eligible for inclusion.

Comparator(s)

The review will consider studies that include, but are not limited to, the following comparators: standard care or no interpreter use and studies that have reported results of comparisons of interventions identified above (duration, frequency and mode of delivery).

Outcomes

The review will consider studies that include the following outcomes: length of stay in hospital, unplanned readmission rates to hospital, non-attendance to hospital clinic appointments and ambulatory care; child and/or parent satisfaction with care in hospital; adherence to treatment, medication errors (including incorrect prescription, administration, dosage and frequency); and other adverse events relating to patient safety (falls, healthcare-associated infections, failure to rescue, pressure areas).

Types of studies

The review will consider all studies conducted using a quantitative approach. Studies will be included in a hierarchical manner where in the absence of experimental/quasi-experimental studies, observational studies and descriptive will be considered for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be used. An initial limited search of MEDLINE (PubMed) and CINAHL (Plus) will be undertaken followed by an analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all included reports and articles will be searched for additional studies. Studies published in English will be searched from the beginning of each database with no specified start date.

The databases to be searched include:

CINAHL Plus, MEDLINE (PubMed), ProQuest, Scopus, Web of Science, Embase, PsycINFO, Science Direct, APAIS Health, AIHW, AustHealth, Factiva, Multicultural Australia and Immigration Studies (MAIS).

The search for studies will include: unpublished studies (via TROVE and OYSTER), conference abstracts, (via ProQuest Theses and Dissertations) and Google Scholar.

Initial keywords to be used will be: migrant, refugee, child, children, pediatrics, paediatrics, interpreters, translators, English as a second language (ESL), low English proficiency, limited English proficiency, Non-English speaking background, hospital, health outcomes, adverse events.

Assessment of methodological quality

Studies selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Quantitative data will be extracted from studies included in the review by two independent reviewers using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data synthesis

Quantitative data will, wherever possible, be pooled in statistical meta-analysis using Review Manager 5 (RevMan v.5.3. Copenhagen: the Nordic Cochrane Centre, Cochrane, Denmark). All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard [chi]²and I² and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data presentation, wherever appropriate.

Acknowledgements

The project is funded by a Research Development Grant from the School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia.

Appendix I: Appraisal instruments

MAStARI appraisal instrument

Appendix II: Data extraction instruments

MAStARI data extraction instrument

References