Ensuring Language Access and Linguistic Competence: A Guide for Researchers

1. It’s the law.
2. Respond to current and emergent demographic trends in the DMV metropolitan area
3. Promote equity in research participation
4. Enhance capacity to address health literacy
5. Enhance capacity to include individuals with disabilities
6. Address implicit biases
7. Add to the body of knowledge on clinical research for LEP populations and those with other communication needs.

• Research is conducted in the preferred language of the study participants.
• Written materials are translated, adapted, and/or provided in alternative formats based on the needs and preferences of the study participants.
• Interpretation and translation services comply with all relevant federal, state, and local mandates governing language access and assistance services.
• People with disabilities are provided accommodations to participate in studies.
• Translated documents are tested prior to using with participants with LEP.
• Researchers use processes to assure the quality of language access services.

Researchers and research team members, such as study coordinators, are not immune to explicit or implicit biases simply by their membership in the helping professions. Bias is often associated with negative thoughts or behaviors; however, bias is simply a preference for one thing, person, or group over another. Bias is a cognitive tendency among humans to make systematic decisions in certain circumstances based on cognitive factors rather than evidence. We as human beings all have biases. Bias is only a concern when it becomes a prejudice against certain people or groups in ways that are unfair and lead to marginalization or discrimination⁴¹.

There is a robust body of literature on biases in medicine and health care and its detrimental effects on diverse patient populations^42-49. This literature also describes myriad biases including studies of individuals with LEP. It illustrates that these biases are present not only among researchers and other research team members, also with Institutional Review Boards (IRBs)⁴⁹. The following questions were adopted for this resource guide from a course, Conscious and Unconscious Biases in Health Care (Georgetown University National Center for Cultural Competence)⁵⁰. They are provided to spur self-reflection and probe the extent to which explicit and implicit biases affect the conduct of research.

• Do my biases:
  • Impact questions and the populations I select for research (e.g., additional level of effort to include some populations, how much accommodations cost to include people with disabilities, the complexities of including populations in study design, implementation, and data analysis)?
  • Influence how I communicate with potential or actual research participants?
  • Interfere with my capacity to interact positively with culturally and linguistically diverse research participants?
  • Hamper my capacity to feel and express empathy toward research participants and the communities in which they live?
• Do you ever perceive that you are less comfortable with research participants who are of a different race, ethnicity, or culture than you?
• Do you believe that recruitment of people with limited English proficiency and/or those with disabilities would be too difficult, burdensome, or costly?
• Do you know whether (or believe that) your colleagues and other staff with whom you routinely interact think that your attitudes and behaviors negatively affect your studies? If so, are you open to discussing these issues and the implications for your research with them?
• Have you elicited the views of community partners about perceived biases?
• Have research participants or their families, directly or through satisfaction surveys, raised concern about your attitude or the way you communicate with them?

The following six interventions represent the evolving body of knowledge of ways to address implicit bias. These interventions, initially designed for health care practitioners, are adapted for health researchers⁵⁰.

1. Acknowledge and accept the existence of implicit bias, its manifestations, and its impact on the conduct of research.
2. Assume individual responsibility to address implicit bias in your work.
3. Engage in self-reflection and self-assessment on an ongoing basis.
4. Make good use of neuroscientific methods to combat “hard wiring” in our brains that labels those who are not like us as “the other.”
5. Collect and use data effectively and perform self-monitoring.
6. Incorporate cultural and linguistic competence in your research and practice.

“The policy of NIH is to provide individuals
with limited English proficiency meaningful
access to NIH conducted programs and
activities, in accordance with the agency’s
needs, capacity assessment, and this Plan.” ⁵³

Know the Law and the Policies

• Be familiar with the policies and practices of your institution’s Language Access Implementation Plan. This plan is a requirement for all institutions receiving federal financial assistance. It describes policy, procedures, and processes to ensure effective communication with persons and communities that are non-English speaking and those with LEP.
• Be familiar with and adhere to the policies of NIH and other HHS funding sources specifically related to the participation of persons with LEP in clinical research^51-52.
• Be familiar with, and adhere to, federal and state policies governing accessibility of public health related research to people with disabilities and those who are deaf or hard of hearing⁵⁴.

Know Your Population

• Determine the number of individuals or segment of the population requiring assistance or accommodations
  to participate in a study that:
  • Speaks languages other than English
  • Are neither literate in English nor their language of origin
  • Have low health literacy
  • Have disabilities that require communication assistance^55-56
  • Are deaf or hard of hearing

Plan for Language Access & Health Literacy

• Determine, plan for, and incorporate the provision of interpretation services for all phases of research to ensure the participation of LEP populations.
• Attend to cultural differences regarding the use of language among populations that speak the same language.
• Determine translation services that will be needed during all phases of research.
• Test the accuracy and readability of translated documents with a sample of the LEP population that will be included in the study.
• Determine and respond to the health literacy needs of potential and enrolled participants, including written and oral communication.
• Determine and incorporate culturally appropriate images and culturally relevant examples in print documents, web-based, and other media when communicating about the study.

Plan your budget accordingly

• Ensure budgets include the cost of language access and linguistic competence services necessary to conduct
  the study. This may include but is not limited to:
  • Salaries for bilingual or multilingual staff who have been vetted, received specialized training, or certified by an accredited organization to provide interpreter or translation services.
  • Sub-contracts with certified professional interpreters; designated budget line items for professional translators;
  • Resources for ethnic media and community organizations that serve linguistically diverse populations;
  • Focus groups with LEP populations to test translated documents;
  • Resources to include people with disabilities who may require accommodations to ensure effective communication;
  • Resources for ASL for people who are deaf or hard of hearing.

Plan for dissemination

• Plan and implement dissemination strategies in partnership with the study population to ensure that research
  findings are:
  • Accessible in languages other than English.
  • Written at the appropriate literacy level.
  • Offered in venues and formats that the populations are likely to access (e.g. ethnic print, television, radio media; faith-based publications and conferences; health fairs; civic organizations; town hall meetings; social media platforms).
  • Accessible to people with disabilities.
  • Specified in the budget and budget narrative including the provision of interpretation, translation, and other communication methods to ensure dissemination to diverse audiences, stakeholders, and constituents.

American Sign Language (ASL) Interpretation

ASL is the most prominent type of interpreting used in the United States. Interpretation occurs between two distinct languages—ASL and English.

• Sign Language Interpreter Tip Sheet
• U. S. Department of Justice, Civil Rights Division, Disability Rights Section: ADA Business Brief: Communicating With People Who Are Deaf or Hard of Hearing in Hospital Settings

Interpreting

The process of understanding and analyzing a spoken or signed message and re-expressing that message
faithfully, accurately, and objectively in another language, taking the cultural and social context into account.

• National Standards of Practice for Interpreters in Health Care (2005). National Council on Interpreting in Health Care.

Interpretation

The oral restating in one language of what has been said in another language; should accurately convey
the tone and meaning of the information given in the original language.

• Goode, T., Sockalingam, S., Brown, M., & Jones, W. (2003). Policy Brief 2: Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: National Center for Cultural Competence. Georgetown University Child Development Center.

The process of understanding and analyzing a spoken or signed message and re-expressing that message faithfully, accurately, and objectively in another language, taking the cultural and social context into account. Interpretation and translation are often incorrectly used interchangeably. The term translation is used for the process of converting written messages from one language to another.

• National Standards of Practice for Interpreters in Health Care (2005). National Council on Interpreting in Health Care

Interpreter

A person who renders a message spoken or signed in one language into a second language. Interpreters strive to render the message accurately, conveying the content and spirit of the original message, taking into consideration the cultural context. Professional interpreters bide by a code of ethics. The terms interpreter and translator are often mistakenly used interchangeably.

• National Standards of Practice for Interpreters in Health Care (2005). National Council on Interpreting in Health Care.

Language Assistance Services

Language assistance services are mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing. These services can include in-person interpreters, bilingual staff, or remote interpreting systems such as telephone or video interpreting. Language services also refer to processes in place to provide translation of written materials or signage, sign language, or Braille materials.

• Department of Health and Human Services, Office of Minority Health (2013). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Rockville, MD.

Limited English Proficiency

As defined by federal legislation, and delineated in policy guidance, limited English proficiency (LEP) refers to individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English.

• Limited English Proficiency, Federal Interagency Website.

Linguistic Competence

There are several definitions of linguistic competence in the health literature. This guide features the conceptual framework and definition of linguistic competence developed by the Georgetown University National Center for Cultural Competence. Linguistic competence is the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse groups including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing. Linguistic competence requires organizational and provider capacity to respond effectively to the health and mental health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity.

• Goode, T.D. & Like, R.C. (2012). Advancing and sustaining cultural and linguistic competence in the American health
  system: Challenges, strategies, and lessons learned. In D. Ingle, A. Chiarenza, I. Kotsioni, and W. Devillé (Eds.), Inequalities in Health Care for Migrants and Ethnic Minorities. COST Series on Health and Diversity Volume II, Antwerp: Garant.
• Goode, T., Wells, N., & Kyu, Rhee (2009). Family-Centered, Culturally and Linguistically Competent Care: Essential Components of the Medical Home. In Turchi, R. & Antonelli, R. (Eds.) Pediatric Annals Special Supplement on the Medical Home. Thoroughfare, NJ: Slack Incorporated.

Plain Language

Plain language, also called plain writing or plain English, is communication your audience can understand the first time they read or hear it. Written materials are in plain language if the intended audience can: 1) find what they need, 2) understand what they find, and 3) use what they find to meet their needs. Plain language is characterized by writing that is clear, concise, well-organized, and follows other best practices appropriate to the subject or field and intended audience.

• What is plain language?

Sign Language Interpreter

An interpreter is a specially trained professional whose job is to convey the messages of people who do not share the same language, culture, or mode of communication. The purpose of providing an interpreter is to allow hearing, deaf, and hard of hearing people equal access to information and interactions.

• Laurent Clerc National Deaf Education Center, Gallaudet University.
• National Deaf Center. Sign Language Interpreters: An Introduction.
• Northern Essex Community College – Faculty & Staff.

• Goode, T., Sockalingam, S., Brown, M. and Jones, W. (2003). Policy Brief 2: Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: National Center for Cultural Competence, Georgetown University Child Development Center.

Translator

A translator is a professional that converts written materials from one language into another language, while maintaining the meaning and cultural nuances of the original written document.

• Goode, T., Sockalingam, S., Brown, M. and Jones, W. (2003). Policy Brief 2: Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: National Center for Cultural Competence, Georgetown University Child Development Center.

¹  NIH Policy and Guidelines on The Inclusion of Women and Minorities as Subjects in Clinical Research. National Institutes of Health, U.S. Department of Health and Human Services, 28 Nov. 2018, https://grants.nih.gov/policy/inclusion/women-and-minorities.htm Accessed 22 March 2022.

²  Chen, Moon S., et al. “Twenty Years Post-NIH Revitalization Act: Enhancing Minority Participation in Clinical Trials (EMPaCT): Laying the Groundwork for Improving Minority Clinical Trial Accrual.” Cancer, vol. 120, 2014, pp. 1091–1096.dio:10.1002/cncr.28575.

³  Kwiatkowski, Kat, et al. “Inclusion of Minorities and Women in Cancer Clinical Trials, a Decade Later: Have We Improved?” Cancer, vol. 119, no. 16, 2013, pp. 2956–2963. doi:10.1002/cncr.28168.

⁴  Hamel, Lauren M et al. “Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer.” Cancer control: journal of the Moffitt Cancer Center vol. 23,4 (2016): 327-337. doi:10.1177/107327481602300404.

⁵  Clark, Luther T., et al. “Increasing Diversity in Clinical Trials: Overcoming Critical Barriers.” Current Problems in Cardiology, vol. 44, no. 5, May 2019, pp. 148–172. doi:10.1016/j.cpcardiol.2018.11.002.

⁶  Ma MA, Gutiérrez DE, Frausto JM, Al-Delaimy WK. Minority Representation in Clinical Trials in the United States: Trends Over the Past 25 Years. Mayo Clin Proc. 2021 Jan;96(1):264-266. doi: 10.1016/j.mayocp.2020.10.027. PMID: 33413830.

⁷  Khan MS, Shahid I, Siddiqi TJ, Khan SU, Warraich HJ, Greene SJ, Butler J, Michos ED. Ten-Year Trends Enrollment of Women and Minorities in Pivotal Trials Supporting Recent US Food and Drug Administration Approval of Novel Cardiometabolic Drugs. J Am Heart Assoc. 2020 Jun 2;9(11):e015594. doi: 10.1161/JAHA.119.015594. Epub 2020 May 19.

⁸  Nazha, Bassel, et al. “Enrollment of Racial Minorities in Clinical Trials: Old Problem Assumes New Urgency in the Age of Immunotherapy.”American Society of Clinical Oncology Educational Book, no. 39, 17 May 2019, pp. 3–10., doi:10.1200/edbk_100021.

⁹  Wise, Cat and Jason Kane, directors. Why Minority Representation in Medical Research Is a Matter of Life and Death. PBS, Public Broadcasting Service, 30 Oct. 2019, www.pbs.org/newshour/show/in-medical-research-racial-diversity-is-a-matter-of-life-or-death.

¹⁰  Fisher, Jill A, and Corey A Kalbaugh. “Challenging assumptions about minority participation in US clinical research.” American journal of public health vol. 101,12 (2011): 2217-22. doi:10.2105/AJPH.2011.300279.          

¹¹ Reaching People in Multiple Languages. National Institute of Minority Health and Health Disparities, U.S. Department of Health and Human Services, www.nimhd.nih.gov/programs/edu-training/language-access/. Accessed 22 March 2022.

¹² Health Information in Multiple Languages. National Institute of Minority Health and Health Disparities. U.S. Department of Health and Human Services, www.nimhd.nih.gov/programs/edu-training/language-access/health-information/. Accessed 22 March 2022.

¹³ Bodicoat, Danielle H et al. “Promoting inclusion in clinical trials-a rapid review of the literature and recommendations for action.” Trials vol. 22,1 880. 4 Dec. 2021, doi:10.1186/s13063-021-05849-7.

¹⁴ Vose J. Minority Enrollment to Clinical Trials: Road to Increased Access. Oncology (Williston Park). 2021 Mar 15;35(3):107. doi: 10.46883/ ONC.2021.3503.0107. PMID: 33818053.

¹⁵ Limited English Proficiency, Guidance to Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. Federal Register Website, Notice by the U.S. Department of Health and Human Services. www.lep.gov/. www.federalregister.gov/documents/2003/08/08/03-20179/guidance-to-federal-financial-assistance-recipients- regarding-title-vi-prohibition-against-national . Accessed 22 March 2022.

¹⁶ Resnik, David B, and Caitlin W Jones. “Research subjects with limited English proficiency: ethical and legal issues.” Accountability in researchvol. 13,2 (2006): 157-77. doi:10.1080/08989620600654043.

¹⁷ Squires, A. “Language barriers and qualitative nursing research: methodological considerations.” International nursing review vol. 55,3 (2008): 265-73. doi:10.1111/j.1466-7657.2008.00652.x.

¹⁸ Agaronnik, Nicole, et al. “Exploring Issues Relating to Disability Cultural Competence among Practicing Physicians.” Disability and Health Journal, vol. 12, no. 3, July 2019, pp. 403–410. doi:10.1016/j.dhjo.2019.01.010.

¹⁹ Agaronnik, Nicole, et al. “Communicating with Patients with Disability: Perspectives of Practicing Physicians.” Journal of General Internal Medicine, vol. 34, no. 7, 2019, pp. 1139–1145. doi:10.1007/s11606-019-04911-0.

²⁰ Kagawa Singer, M et al. “Culture: The missing link in health research.” Social science & medicine (1982) vol. 170 (2016): 237-246. doi:10.1016/j.socscimed.2016.07.015.

²¹ Kagawa Singer, M et al. “The cultural framework for health: An integrative approach for research and program design and evaluation.” ResearchGate, 2015 https://www.researchgate.net/publication/273970021_The_cultural_framework_for_health_An_integrative_approach_ for_research_and_program_design_and_evaluation

²² Gilbert, M. Jean, et al. “Process of Inquiry—Communicating in a Multicultural Environment. From the Curricula Enhancement Module Series.” Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development, 2005, https://nccc.georgetown.edu/curricula/documents/processofinquiry.pdf.

²³ Title VI of the 1964 Civil Rights Act: 42 U.S.C § 2000D ETSEQ. The United States Department of Justice, Civil Rights Division. https://www.justice.gov/crt/fcs/TitleVI-Overview. Accessed 22 March 2022.

²⁴ Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. U.S. Department of Health and Human Services. www.hhs.gov/civil-rights/for-individuals/special-topics/limited- english-proficiency/guidance-federal-financial-assistance-recipients-title-vi. Accessed 22 March 2022.

²⁵ National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, U.S. Department of Health and Human Services. https://thinkculturalhealth.hhs.gov/clas/standards. Accessed 22 March 2022.

²⁶ District of Columbia Office of Human Rights. Know Your Rights: Language Access. https://ohr.dc.gov/service/know-your-rights-language- access Accessed 28 March 2018.

²⁷ U.S. Census Bureau, Languages Spoken at Home in the District of Columbia, 2020 American Community Survey Five Year Estimate Table S1601. U.S. Census Bureau, 2020. https://data.census.gov/cedsci/table?q=S1601%3A%20LANGUAGE%20SPOKEN%20AT%20 HOME&g=310XX00US47900&tid=ACSST5Y2020.S1601 Accessed 21 March 2022.

²⁸ U.S. Census Bureau, Limited English Speaking Households in the District of Columbia, 2020 American Community Survey Five Year Estimate Table S1602. U.S. Census Bureau, 2020. https://data.census.gov/cedsci/table?q=s1602%3A%20district%20of%20District%20 of%20Columbia,%20District%20of%20Columbia Accessed 21 March 2022.

²⁹ US Census Bureau, Frequently Asked Questions about Language Use. What is a limited English Speaking Household? Last revised December 3, 2021. https://www.census.gov/topics/population/language-use/about/faqs.html#:~:text=What%20is%20a%20Limited%20English,least%20some%20difficulty%20with%20English. Accessed 22 March 2022.

³⁰ U.S. Census Bureau, Language Spoken at Home for the Population 5 Years and Over in DC, MD VA, WV Micro Statistical Area, ACS 2020 Year 5 Estimates. Table S1601. U.S. Census Bureau, 2020, https://data.census.gov/cedsci/table?q=S1601%3A%20LANGUAGE%20 SPOKEN%20AT%20HOME&g=310XX00US47900&tid=ACSST5Y2020.S1601  Accessed March 21, 2022.

³¹ U.S. Census Bureau, Limited English Speaking Households in DC,MD, VA, WV Micro Statistical Area, ACS 2020 Year 5 Estimates, Table 1602. U.S Census Bureau, 2020. https://data.census.gov/cedsci/table?q=S1601%20Limited%20English%20Speaking%20 Households&g=310XX00US47900&tid=ACSST5Y2020.S1602

³² Institute of Medicine (US) Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Edited by Lynn Nielsen-Bohlman et. al., National Academies Press (US), 2004. doi:10.17226/10883.

³³ Yee, Breslin, et al. “Compounded Disparities: Health Equity at the Intersection of Disability, Race, and Ethnicity.” Washington, DC: The National Academies of Science, Engineering and Medicine, 2018, https://www.nationalacademies.org/our-work/the-intersections-between- health-disparities-disabilities-and-health-equity-a-workshop#resources.                      

³⁴ Rudd, McCray A, and Nutbeam D. Health Literacy and Definition of Terms. In: Begoray D, Gillis D, Rowlands G, eds. Health Literacy in Context: International Perspective. New York. NY: Nova Science Publishers, Inc; 2012.

³⁵ Leak, Cardella, et al. “Effect of Health Literacy on Research Follow-Up.” Journal of Health Communication, vol. 20, no. sup2, 2015, pp. 83–91. doi:10.1080/10810730.2015.1058442.

³⁶ Kripalani, Sunil, et al. “Association of Health Literacy and Numeracy with Interest in Research Participation.” Journal of General Internal Medicine, vol. 34, no. 4, 2019, pp. 544–551. doi:10.1007/s11606-018-4766-2.

³⁷ Killian, Lara, and Margo Coletti. “The Role of Universal Health Literacy Precautions in Minimizing ‘Medspeak’ and Promoting Shared Decision Making.” AMA Journal of Ethics, vol. 19, no. 3, 2017, pp. 296–303. doi:10.1001/journalofethics.2017.19.3.pfor1-1703.

³⁸ What Did My Doctor Say?. Medical Library Association, www.mlanet.org/p/cm/ld/fid=580. Accessed 20 March 2020.

https://www. plainlanguage.gov/

³⁹ The Plain Language Writing Act of 2010, Public Law 111-172. plainlanguage.gov. https://www.plainlanguage.gov/law/. Accessed 22 March 2022.

⁴⁰ What Is Plain Language? Plainlanguage.gov. https://www.plainlanguage.gov/about/definitions. Accessed 22 March 2022.

⁴¹ The Current State of Health Care for People with Disabilities. NCD.gov, 23 June 2016, www.ncd.gov/publications/2009/Sept302009.

⁴² Krahn, Gloria L et al. “Persons with disabilities as an unrecognized health disparity population.” American journal of public health vol. 105 Suppl 2,Suppl 2 (2015): S198-206. doi:10.2105/AJPH.2014.302182.

⁴³ Rios, Dianne et al. “Conducting Accessible Research: Including People With Disabilities in Public Health, Epidemiological, and Outcomes Studies.” American journal of public health vol. 106,12 (2016): 2137-2144. doi:10.2105/AJPH.2016.303448.

⁴⁴ Chinn, Deborah. “Critical Health Literacy Health Promotion and People with Intellectual Disabilities.” Asia-Pacific Journal of Health, Sport and Physical Education, vol. 5, no. 3, 2014, pp. 249–265. doi:10.1080/18377122.2014.940811.

⁴⁵ Mudrick, Nancy R., et al. “Physical Accessibility in Primary Health Care Settings: Results from California on-Site Reviews.” Disability and Health Journal, vol. 5, no. 3, 2012, pp. 159–167. doi:10.1016/j.dhjo.2012.02.002.

⁴⁶ Feldman, M. A., et al. “Where Are Persons with Intellectual Disabilities in Medical Research? A Survey of Published Clinical Trials.” Journal of Intellectual Disability Research, vol. 58, no. 9, 2013, pp. 800–809. doi:10.1111/jir.12091.

⁴⁷ Peris, Tara S, et al. “Implicit and explicit stigma of mental illness: links to clinical care.” The Journal of nervous and mental disease vol. 196,10 (2008): 752-60. doi:10.1097/NMD.0b013e3181879dfd.

⁴⁸ Flores, Glenn, et al. “A Successful Approach to Minimizing Attrition in Racial/Ethnic Minority, Low-Income Populations.” Contemporary Clinical Trials Communications, vol. 5, 2017, pp. 168–174. doi:10.1016/j.conctc.2017.01.009.

⁴⁹ Sheppard, Vanessa B., et al. “An Examination of Factors Associated with Healthcare Discrimination in Latina Immigrants: The Role of Healthcare Relationships and Language.” Journal of the National Medical Association, vol. 106, 2014, pp. 15–22. doi:10.1016/s0027- 9684(15)30066-3.

⁵⁰ Wasserman, Melanie, et al. “Identifying and Preventing Medical Errors in Patients With Limited English Proficiency: Key Findings and Tools for the Field.” Journal For Healthcare Quality, vol. 36, no. 3, 2014, pp. 5–16., doi:10.1111/jhq.12065.

⁵¹ Betancourt, Joseph R., and Aswita Tan-Mcgrory. “Creating a Safe, High-Quality Healthcare System for All:Meeting the Needs of Limited English Proficient Populations; Comment on ‘Patient Safety and Healthcare Quality: the Case for Language Access.’” International Journal of Health Policy and Management, vol. 2, no. 2, 2014, pp. 91–94. doi:10.15171/ijhpm.2014.21.

⁵² Flores, Glenn. “Families Facing Language Barriers in Healthcare: When Will Policy Catch Up with the Demographics and Evidence?” The Journal of Pediatrics, vol. 164, no. 6, 2014, pp. 1261–1264. doi:10.1016/j.jpeds.2014.02.033.

⁵³ Mosquera, R. A., et al. “Family Language Barriers and Special-Needs Children.” Pediatrics, vol. 138, no. 4, 2016. doi:10.1542/peds.2016- 0321.

⁵⁴ Green, Alexander R., and Chijioke Nze. “Language-Based Inequity in Health Care: Who Is the ‘Poor Historian’?” AMA Journal of Ethics, vol. 19, no. 3, 2017, pp. 263–271. doi:10.1001/journalofethics.2017.19.3.medu1-1703.

⁵⁵ Jones, Caitlin W., and David B. Resnik. “Research Subjects with Limited English Proficiency: Ethical and Legal Issues.” Accountability in Research, vol. 13, no. 2, 2006, pp. 157–177. doi:10.1080/08989620600654043.

⁵⁶ Milligan M., Tew-Washburn, S., Millier-Doss, K., & Giamrone, J. Disability Studies Quarterly . Vol. 39 No. 1. (2019). Winter 2019. https://dsq- sds.org/article/view/6062/5188. Accessed 22 March 2022.

57 “Conscious & Unconscious Biases in Health Care.” Georgetown University National Center for Cultural Competence, Georgetown. https:// nccc.georgetown.edu/bias/index.php. Accessed 22 March 2022.

⁵⁸ Access and Equity in Your Language – About. National Institutes of Health, U.S. Department of Health and Human Services, https://www.edi.nih.gov/consulting/language-access-program/about. Accessed 22 March 2022.

⁵⁹ Language Access Program – Frequently Asked Questions. National Institutes of Health, U.S. Department of Health and Human Services, https://www.edi.nih.gov/consulting/language-access-program/faqs. Accessed 22 March 2022.

⁶⁰ NIH Language Access Plan 2014. National Institutes of Health, https://www.edi.nih.gov/consulting/language-access-program/about. Accessed 22 March 2022.

⁶¹ ADA Quick Tips – Sign Language Interpreters. ADA National Network. https://adata.org/factsheet/sign-language-interpreters. Accessed 22 March 2022.

⁶² Rios, Dianne, et al. “Conducting Accessible Research: Including People With Disabilities in Public Health, Epidemiological, and Outcomes Studies.” American Journal of Public Health, vol. 106, no. 12, 2016, pp. 2137–2144. doi:10.2105/ajph.2016.303448.

⁶³ Williams, A. S., and S. M. Moore. “Universal Design of Research: Inclusion of Persons with Disabilities in Mainstream Biomedical Studies.”Science Translational Medicine, vol. 3, no. 82, 2011, pp. 82cm12-82cm12., doi:10.1126/scitranslmed.3002133.

Watch the webinar about the Language Access Guide featuring Professor Goode, a member of the GHUCCTS Community Engagement Team and Director of the National Center for Cultural Competence.

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