












































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 
 

Strategies to Improve Healthcare Communication with Non-Native 
English Speakers: An Evidence to Practice Review 
Skylar B. Hudgens-Wallace, MS, ATC*; Kaitlyn M. Pierce, MS, ATC‡; Madison P. Whitesell MS, ATC†; Nancy A. Uriegas, MS, 
ATC§; Zachary K. Winkelmann, PhD, SCAT, ATC, CHSE§ 
*Ochsner Sports Medicine Institute, New Orleans, LA; ‡Life University, Marietta, GA; †Moore Myoworx, Denver, CO; §University of 
South Carolina, Columbia, SC  
 

 
ABSTRACT 
As the number of non-native English speakers in the United States rises, the degree to which some patients understand their healthcare 
communication is decreasing. It is essential to recognize the areas of limited health literacy to ensure proper patient communication 
and education are achieved. The guiding systematic review aimed to examine different communication interventions and the reported 
patient experiences from those interactions. The main forms of healthcare communication interventions used in the study included in-
person, telephone, and video call interpreters. Patients have been shown to respond best to in-person interpreters, but using 
interpreters via telephone or video call was also effective and a suitable option. Athletic trainers could use interpreters via telephone 
or video call to provide patients with a better understanding of their injury while improving communication between the provider 
and patient. The clinical bottom line of the guiding systematic review was to provide multiple forms of communication interventions 
to ensure the best outcome of health literacy for the patient. Athletic trainers and other healthcare providers can advocate for non-
native English speakers by creating a healthcare communication policy that includes on-demand interventions such as a translation 
application or a formal medical interpreter. 
Content Focus: Health Care Competency  
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Hudgens-Wallace SB, Pierce KM, Whitesell MP, Uriegas NA, Winkelmann ZK. Strategies to improve healthcare communication 
with non-native English speakers: An evidence to practice review. Clin Pract Athl Train. 2023;6(2): 28-36. 
https://doi.org/10.31622/2023/0006.02.4.  
 

 
ORIGINAL REFERENCE 
Rajiv P, Riggs E, Brown S, Szwarc J, Yelland J. Communication interventions to support people with limited 
English proficiency in healthcare: a systematic review. J Healthc Commun. 2021;14(2):176-187. 
doi:10.1080/17538068.2021.1890518 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Patient-centered care is defined as care that is respectful of and responsive to individual patient 
preferences, needs, and values and that ensures that patient values guide all clinical decisions.1 Using 
patient-centered principles is essential to provide the best care available for patients, which includes 
shared decision-making and a holistic approach involving the social determinants of health.2 The social 
determinants of health dissect the driving forces behind social, environmental, and behavioral risk factors 
for poor physical and mental health.2 One of these factors is information and education, which indicates 
that patients often express fear that information is being withheld from them and not being completely 
informed about their condition. Appreciation of some of the social factors that influence health-related 
behaviors and health status can help clinicians develop more effective treatment plans.3  

 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2023/0006.02.4


Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

Proper communication can potentially improve the patient’s health literacy, defined as the degree to which 
individuals can obtain, process, and understand basic health information and services needed to make 
appropriate health decisions.4 Increasing patient health literacy can greatly improve overall patient-
centered care. Comprehending and fully understanding the information provided can be difficult for most 
patients; however, the struggle could be magnified for patients and their support systems as non-native 
English speakers. The United States does not have a federal official language. Still, most states have laws 
indicating English as the declared language, with more than 20 regional dialects and over 250 million 
native speakers.5 Outside of English, the most common languages in the United States include Spanish (43 
million native speakers and rising)6 and Chinese (3 million native speakers). In addition, it is important to 
note that there are estimates between 250,000-500,000 American Sign Language users in the United 
States.7 These data points emphasize the diversity of the languages used throughout the population and 
the need for providers to meet their needs in terms of communication. 

A study conducted in the United States assessed individuals' health literacy, indicating that over one-third 
of Americans (36%) with below basic or basic health literacy were less likely to get information about their 
health issues.8 Unfortunately, healthcare providers in the United States have seen an increase in patients 
with limited English proficiency. The language barrier may often hinder communication between patients 
and providers, highlighting the health disparity even further and increasing the chance for poor outcomes. 
However, it is important to note that using family members, teachers, friends, teammates, or coaches as 
interpreters can burden a patient’s health literacy and possibly compromise private health information.9 
This is also true when asking an injured bilingual patient, specifically a minor at a secondary school, to 
interpret for themselves back to their non-English speaking support systems (e.g., parents, guardians, 
caretakers). Limited resources for non-native English speakers across sports can affect their access to 
healthcare and patient outcomes. Patients need to be able to understand diagnosis, injury instructions, 
treatment, and therapeutic interventions. The primary clinical question for the guiding systematic review 
was to examine different communication interventions and the reported patient experiences for individuals 
with limited English proficiency.  

SUMMARY OF LITERATURE  

The guiding systematic review authors used MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane 
Library in their search for the articles used in this review.10  All articles were published between 2009 and 
2020 in English and incorporated a verbal communication intervention.10  Additionally, studies were 
included if they met design characteristics for a randomized control trial (RCT) and patient outcomes that 
were the focus of this study.10  Studies were excluded if they included deaf or hearing-impaired 
populations, excluded only written communication interventions, or the study did not report patient 
outcomes.10 Data were categorized into five types based on the type of communication support 
implemented: (1) professional interpretation, (2) audio and visual recording of consultation, (3) bilingual 
physician aids, (4) translation applications, and (5) written instructions supported by verbal 
interpretation.10 Database searches resulted in 4297 studies after eligibility screening, and 23 studies met 
all the criteria for the systematic review.10   Of the studies included in the review, 12 RCTs were included, 
with no blinding achieved in these studies.10 Five out of the 12 had similar patient characteristics at 
baseline and clearly recorded outcome measurements.11-15 There were 11 non-RCTs included in the 
review.10   Out of the 11 of the non-RCTs, none had reported multiple measures of outcomes pre- and 
post-intervention, and only one had clear documentation.16 Baseline characteristics were similar within only 
3 out of the 11 non-RCTs.16-18 For the 23 included studies, the assessment of methodological quality 
determined the studies to be of moderate quality.10 



Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

SUMMARY OF INTERVENTIONS 

The guiding systematic review authors included interventions for improving communication for non-English 
speaking patients receiving care in predominantly English-speaking countries. The two main interventions 
included either interpreters or translators. Figure 1 provides a brief overview of the difference between 
interpreters and translators. Fifteen of the included studies implemented the use of professional 
interpreters to improve communication. Professional interpreters included in-person interpreters via 
telephone or via video call.11,12,14,16,18-27 Two of the included studies reviewed bilingual practitioners 
communicating with patients in their native languages. Other studies examined the use of recordings to 
assist in the translation and explanation of procedures. One study implemented the use of Google Translate 
to translate into the patient's native language during primary care visits. Three studies looked at the use of 
visual and written explanations of medical information. Some studies wrote the information in the patient's 
preferred language, and others used visual aids such as a pictogram accompanied by an audible 
explanation.  

 

 

Figure 1. Definition of Interventions 

 

SUMMARY OF OUTCOMES 

Twenty-three studies from the United States, Australia, Canada, India, Sweden, Germany, and Qatar were 
used to evaluate language barriers between patients and healthcare professionals.11-33 Most language 
groups included Spanish and Chinese-speaking patients.11,12,14-16,19,21,23,25,26,29,32-34 The group of 
researchers evaluated communication in the Emergency Department as well as post-operative rooms, 

•Spoken language interpretation service
•Can occur in unison or consecutive speech
•Communicates directly with the patient and the 
provider in real time in both source and target 
languages (e.g. English and Spanish)

•Provides sentence-by-sentence interpretation

Interpreter

•Written word translation service
•Typically provided using a digital tool and computer 
resources

•Occurs over time; not real-time
•Usally translates unidirectionally into native 
language (e.g. translating patient education file 
from English into Spanish for non-native English 
speaker)

Translator



Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

general hospitals, and birthing suites that used professional interpretation, audio and visual recordings of 
consultations, bilingual physician aids, translation applications, and written instructions supported by verbal 
interpretation.11,12,14-17,19,21-23,29,32 Following the implementation of these methods, the most commonly 
evaluated patient outcomes were “patient satisfaction” and “patient comprehension.”11-19,23-26,29-33,35 A 
total of 15 out of the 23 studies had resulted in a preference for in-person interpretation versus video-
conference interpretation.11,12,14,18-21,24,25,27,33 Evaluation of bilingual physicians or bilingual tools used in the 
clinic also occurred in these studies.  

FINDING AND CLINICAL IMPLICATIONS 

Patient outcomes were measured as “patient satisfaction” and “patient comprehension.” Of the 23 studies, 
20 compared patient outcomes between in-person interpreters, interpreters via telephone, and interpreters 
via video conference. Most patients self-reported being satisfied during their visits based on the 
knowledge of their diagnosis, treatment, and associated risks. While patients reported being satisfied with 
video conference interpreters, 82% of patients preferred in-person interpretation over the other, stating 
video-conference interpretation performed the ‘same,’ ‘worse,’ or ‘much worse.’ However, 98% of 
participants said they were satisfied with the video-conference encounter. 21,33  When comparing 
telephone interpretation versus video-conference interpretation, video-conference interpretation was 
preferred.21 Most patients who were able to use bilingual tools in the clinic saw increased communication 
during their visit. The satisfaction of Google Translate compared to in-person interpretation proved to be 
comparable, although the accuracy of translation was not evaluated.31  

CLINICAL BOTTOM LINE 

The lack of formal training for providing care for non-native English speakers could have negatively 
outcomes as providers have not been educated or know what resources they have available to them for 
support.9 Using different communication interventions could be beneficial for non-native English-speaking 
patients to understand their health and healthcare fully. Implementing different communication 
interventions, like using a professional interpreter, could be expensive and not as applicable to some 
athletic training facilities throughout the United States, but potentially beneficial. However, it is important 
to note the legal and ethical obligation under Title VI of the Civil Rights Act to provide and use a trained 
interpreter.36 Based on the findings in the studies, more information regarding the use of interpretation in 
athletic training facilities is needed. Based on the results from other healthcare settings, it can be assumed 
that athletic trainers providing care to non-native English-speaking populations or their support systems 
should use an interpreter to provide the best patient care. If possible, in-person interpreters should be 
utilized by having them sit next to or behind the patient.36 The athletic trainer should also speak directly to 
the patient in the first person rather than with the interpreter.36 The best practices for integrating a medical 
interpreter also highlight patient-centered communication, such as speaking in short sentences, asking only 
one question at a time, avoiding medical jargon, and using a ‘teach back’ to check comprehension.36  

However, athletic trainers may not always have access to in-person interpreters and should, therefore, use 
interpreters via video conferencing or could consider using more nonverbal communication when providing 
care for these patients. This could maximize health information technology to be able to share information 
through images and resources.9 Athletic trainers can advocate for our non-native English-speaking patients 
by obtaining tools for video-conference interpretation and/or Google Translate to ensure that their 
patients fully understand their health. Obtaining translation tools for non-native English-speaking patients 
can help enhance the environment in athletic training facilities.9 Furthermore, it can help demonstrate to 
patients that the healthcare system does not have to be confusing or difficult to navigate for them or their 



Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

families.9 Knowing a list of common terms in Spanish could be beneficial when you are not able to use a 
translator. Table 1 provides a list of common medical terminology with phonetic pronunciations to assist 
athletic trainers. As seen in the guiding systematic review, the use of bilingual tools can increase 
communication during patient visits, and having bilingual patient-reported outcomes, sign-in sheets, health 
history forms, and any other intake forms can help to make the patient comfortable and more receptive to 
treatment. There are several free tools available, like Translate on the Apple App Store and Google 
Translate, that can help when using a videoconference or in-person interpreter is not accessible. Ultimately, 
improving communication with the patient and others involved in their care is essential to prevent improper 
care that can lead to poor patient satisfaction and serious injury.37-40 As we continue to work towards a 
more patient-centered approach to athletic training, we have to recognize the promotion of health literacy 
as a risk-reduction technique. The use of resources relative to health literacy for non-native English 
speakers and for athletic trainers caring for or communicating with non-native English speakers is critical 
for success with our diverse patient panels.  

  



Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

Table 1. Common Terms and Phrases 
Healthcare Terms (English) Healthcare Terms (Spanish) Phonetics of Spanish Translation 
Surgery La cirugia Lah see-roo-hee-ah 
Concussion La concusión Lah kohn-cuh-syohn 
Insurance El seguro médico Ehl seh-goo-roh meh-dee-co 
Pain El dolor Ehl doh-lohr 
Fever La fiebre Lah fyeh-breh 
Hip La cadera Lah kah-deh-rah 
Dizziness El mareo Ehl mah-reh-oh 
Inflammation La inflamacion Lah eem-flah-mah-syohn 
Rehabilitation La fisioterapia Lah fee-syoh-the-rah-pyah 
Ankle El tobillo Ehl toh-bee-yoh 
Healthcare Phrases (English) Healthcare Phrases (Spanish) Phonetics of Spanish Translation 
Where does it hurt? ¿Donde te duele? Dohn-deh teh dweh-leh 
Point to where it hurts? ¿Señala dónde te duele? Seh-nyah-lah dohn-deh dweh-leh 

Do you take any medication? ¿Tomas algún medicamento? Toh-mahs ahl-goo-noh meh-dee-kah-mehn-
toh 

What is your diet like? ¿Cómo es tu dieta? Koh-moh ehs too dyeh-tah 

Is the pain better or worse at night? ¿El dolor es mejor o peor por la 
noche? 

Ehl doh-lohr ehs meh-hohr oh peh-ohr pohr 
lah noh-cheh 

Did you bang/hit your head? ¿Te golpeaste la cabeza? Teh gohl-peh-ahr kah-beh-sah 
He is going to the emergency room. Él va a la sala de emergencias. Bah-ah-lah sah-lah deh eh-mehr-hehn-syah 
She fractured her wrist. Se fracturó la muñeca. Seh-frahk-too-rahr lah-moo-nyeh-kah 
Did you get stung? ¿Te picó? Teh-pee-ko 
When did you faint? ¿Cuándo te desmayaste? Kwahn-doh teh dehs-mah-yahr 

 

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Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 6 – Issue 2 – September 2023 

39. Sodemann M, Kristensen TR, Sångren H, Nielsen D. Barriers to communication between clinicians and 
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https://doi.org/10.1177%2F0009922816629760

	ABSTRACT

