MANUSCRIPT TYPE EVIDENCE-TO-PRACTICE REVIEW 28 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 29 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 30 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 31 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 32 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 33 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 REFERENCES 1. Barry MJ, Edgman-Levitan S. Shared decision making — The pinnacle patient-centered care. N Engl J Med. 2012;366(9):780-781. https://doi.org/10.1056/nejmp1109283. 2. Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep. 2014;129(1_suppl2):19-31. https://doi.org/10.1177%2F00333549141291S206. 3. Fiscella K, Tancredi D, Franks P. Adding socioeconomic status to Framingham scoring to reduce disparities in coronary risk assessment. Am Heart J. 2009;157(6):988-994. https://doi.org/10.1016/j.ahj.2009.03.019. 4. Rudd RE, Anderson JE, Oppenheimer S, Nath C. Health literacy: an update of medical and public health literature. Review of adult learning and literacy. 2007;7:175-203. 5. Arington M. English-only laws and direct legislation: The battle in the states over language minority rights. JL & Pol. 1990;7:325. 6. Lopez MH, González-Barrera A. What is the future of Spanish in the United States. Pew Research Center. 2013;5. 7. Mitchell RE, Young TA, Bachelda B, Karchmer MA. How many people use ASL in the United States? Why estimates need updating. Sign Lang Stud. 2006;6(3):306-335. http://dx.doi.org/10.1353/sls.2006.0019. https://doi.org/10.1056/nejmp1109283 https://doi.org/10.1177%2F00333549141291S206 https://doi.org/10.1016/j.ahj.2009.03.019 http://dx.doi.org/10.1353/sls.2006.0019 Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 34 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 6 – Issue 2 – September 2023 8. Ratzan SC, Parker RM. Health literacy - identification and response. J Health Commun. 2006;11(8):713-715. https://doi.org/10.1080/10810730601031090. 9. Stanton BM, Rivera MJ, Winkelmann ZK, Eberman LE. Non-Native English-Speaking Patients, Support Systems, and Patient Care Delivery: A Study of Secondary School Athletic Trainers. J Athl Train. 2022;57(2):148-157. https://doi.org/10.4085/1062-6050-0181.21. 10. 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 Commun Healthc. 2021;14(2):176-187. https://doi.org/10.1080/17538068.2021.1890518. 11. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S, Zavotsky K, Eisenstein R. Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: results of a randomized controlled trial. Ann Emerg Med. 2011;57(3):248-256. e244. https://doi.org/10.1016/j.annemergmed.2010.05.032. 12. Crossman KL, Wiener E, Roosevelt G, Bajaj L, Hampers LC. Interpreters: telephonic, in-person interpretation and bilingual providers. Pediatrics. 2010;125(3):e631-e638. https://doi.org/10.1542/peds.2009-0769. 13. Kheir N, Awaisu A, Radoui A, El Badawi A, Jean L, Dowse R. Development and evaluation of pictograms on medication labels for patients with limited literacy skills in a culturally diverse multiethnic population. Res Social Adm Pharm. 2014;10(5):720-730. https://doi.org/10.1016/j.sapharm.2013.11.003. 14. Lion KC, Brown JC, Ebel BE, et al. Effect of telephone vs video interpretation on parent comprehension, communication, and utilization in the pediatric emergency department: a randomized clinical trial. JAMA Pediatr. 2015;169(12):1117-1125. https://doi.org/10.1001/jamapediatrics.2015.2630. 15. West AM, Bittner EA, Ortiz VE. The effects of preoperative, video-assisted anesthesia education in Spanish on Spanish-speaking patients’ anxiety, knowledge, and satisfaction: a pilot study. J Clin Anesth. 2014;26(4):325-329. https://doi.org/10.1016/j.jclinane.2013.12.008. 16. Lee JS, Pérez-Stable EJ, Gregorich SE, et al. Increased access to professional interpreters in the hospital improves informed consent for patients with limited English proficiency. J Gen Intern Med. 2017;32(8):863-870. https://doi.org/10.1007/s11606-017-3983-4. 17. Han A, Laranjo H, Friedman SM. The design and pilot of a translation aid to help ED clinicians enhance communication with the Portuguese-speaking patient. Int J Emerg Med. 2009;2(1):41-46. https://doi.org/10.1007%2Fs12245-008-0081-8. 18. Schulz TR, Leder K, Akinci I, Biggs B-A. Improvements in patient care: videoconferencing to improve access to interpreters during clinical consultations for refugee and immigrant patients. Aust Health Rev. 2015;39(4):395-399. https://doi.org/10.1071/ah14124. 19. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S. Using professionally trained interpreters to increase patient/provider satisfaction: does it work? : Mathematica Policy Research;2010. 20. Brune M, Eiroa-Orosa FJ, Fischer-Ortman J, Delijaj B, Haasen C. Intermediated communication by interpreters in psychotherapy with traumatized refugees. Int J Cult Ment Health. 2011;4(2):144-151. http://dx.doi.org/10.1080/17542863.2010.537821. 21. Grover A, Deakyne S, Bajaj L, Roosevelt GE. Comparison of throughput times for limited English proficiency patient visits in the emergency department between different interpreter modalities. J Immigr Minor Health. 2012;14(4):602-607. https://doi.org/10.1007/s10903-011-9532-z. 22. Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient access to professional interpreters in the hospital decreases readmission rates and estimated hospital expenditures for patients with limited English proficiency. Med Care. 2017;55(3):199. https://doi.org/10.1097/mlr.0000000000000643. https://doi.org/10.1080/10810730601031090 https://doi.org/10.4085/1062-6050-0181.21 https://doi.org/10.1080/17538068.2021.1890518 https://doi.org/10.1016/j.annemergmed.2010.05.032 https://doi.org/10.1542/peds.2009-0769 https://doi.org/10.1016/j.sapharm.2013.11.003 https://doi.org/10.1001/jamapediatrics.2015.2630 https://doi.org/10.1016/j.jclinane.2013.12.008 https://doi.org/10.1007/s11606-017-3983-4 https://doi.org/10.1007%2Fs12245-008-0081-8 https://doi.org/10.1071/ah14124 http://dx.doi.org/10.1080/17542863.2010.537821 https://doi.org/10.1007/s10903-011-9532-z https://doi.org/10.1097/mlr.0000000000000643 Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 35 Copyright © by Indiana State University Clinical Practice in Athletic Training All rights reserved. ISSN Online 2577-8188 Volume 6 – Issue 2 – September 2023 23. Lee JS, Nápoles A, Mutha S, et al. Hospital discharge preparedness for patients with limited English proficiency: a mixed methods study of bedside interpreter-phones. Patient Educ Couns. 2018;101(1):25-32. https://doi.org/10.1016/j.pec.2017.07.026. 24. Locatis C, Williamson D, Gould-Kabler C, et al. Comparing in-person, video, and telephonic medical interpretation. J Gen Intern Med. 2010;25(4):345-350. https://doi.org/10.1007%2Fs11606-009- 1236-x. 25. Locatis C, Williamson D, Sterrett J, Detzler I, Ackerman M. Video medical interpretation over 3G cellular networks: A feasibility study. Telemed J E Health. 2011;17(10):809-813. https://doi.org/10.1089%2Ftmj.2011.0084. 26. Meischke H, Ike B, Painter I, et al. Delivering 9-1-1 CPR instructions to limited english proficient callers: a simulation experiment. J Immigr Minor Health. 2015;17(4):1049-1054. https://doi.org/10.1007/s10903-014-0017-8. 27. Yelland J, Biro MA, Dawson W, et al. Bridging the language gap: a co-designed quality improvement project to engage professional interpreters for women duing labour. Aust Health Rev. 2016;41(5):499- 504. https://doi.org/10.1071/ah16066. 28. Hyatt A, Lipson‐Smith R, Gough K, et al. Culturally and linguistically diverse oncology patients' perspectives of consultation audio‐recordings and question prompt lists. Psychooncology. 2018;27(9):2180-2188. https://doi.org/10.1002/pon.4789. 29. Jang M, Plocienniczak MJ, Mehrazarin K, Bala W, Wong K, Levi JR. Evaluating the impact of translated written discharge instructions for patients with limited English language proficiency. Int J Pediatr Otorhinolaryngol. 2018;111:75-79. https://doi.org/10.1016/j.ijporl.2018.05.031. 30. Lipson‐Smith R, Hyatt A, Butow P, et al. Are audio recordings the answer?—a pilot study of a communication intervention for non‐English speaking patients with cancer. Psychooncology. 2016;25(10):1237-1240. https://doi.org/10.1002/pon.4193. 31. Sreekanth G. The use of Google language tools as an interpretation aid in cross-cultural doctor– patient interaction: a pilot study. Inform Prim Care. 2010;18(2):141-143. https://doi.org/10.14236/jhi.v18i2.764. 32. Stoneking LR, Waterbrook AL, Garst Orozco J, et al. Does Spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?. Adv Med Educ Pract. 2016;7:467-473. https://doi.org/10.2147/amep.s110177. 33. Wofford JL, Campos CL, Johnson DA, Brown MT. Providing a Spanish interpreter using low-cost videoconferencing in a community study computers. J Innov Health Inform. 2013;20(2):141-146. http://dx.doi.org/10.14236/jhi.v20i2.34. 34. The show must go on: Band in 2 July 4 parades deals with extreme heat. CBS News. July 5, 2018. Accessed August 23, 2023. https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood- parade-marching-band-saints-brigade-extreme- heat/#:~:text=Due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on. 35. Yeung SSY, Trappenburg MC, Meskers CGM, Maier AB, Reijnierse EM. The use of a portable metabolic monitoring device for measuring RMR in healthy adults. Br J Nutr. 2020;124(11):1229- 1240. https://doi.org/10.1017%2FS0007114520001014. 36. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-480. 37. Forrow L, Kontrimas JC. Language Barriers, Informed Consent, and Effective Caregiving. J Gen Intern Med. 2017;32(8):855-857. https://doi.org/10.1007%2Fs11606-017-4068-0. 38. Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659-666. https://doi.org/10.1097/mop.0000000000000404. https://doi.org/10.1016/j.pec.2017.07.026 https://doi.org/10.1007%2Fs11606-009-1236-x https://doi.org/10.1007%2Fs11606-009-1236-x https://doi.org/10.1089%2Ftmj.2011.0084 https://doi.org/10.1007/s10903-014-0017-8 https://doi.org/10.1071/ah16066 https://doi.org/10.1002/pon.4789 https://doi.org/10.1016/j.ijporl.2018.05.031 https://doi.org/10.1002/pon.4193 https://doi.org/10.14236/jhi.v18i2.764 https://doi.org/10.2147/amep.s110177 http://dx.doi.org/10.14236/jhi.v20i2.34 https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7E:text=Due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7E:text=Due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7E:text=Due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://doi.org/10.1017%2FS0007114520001014 https://doi.org/10.1007%2Fs11606-017-4068-0 https://doi.org/10.1097/mop.0000000000000404 Strategies to Improve Healthcare Communication with Non-Native English Speakers: An Evidence to Practice Review 36 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 immigrants. Ugeskrift for laeger. 2015;177(35). 40. Steinberg EM, Valenzuela-Araujo D, Zickafoose JS, Kieffer E, DeCamp LR. The "Battle" of Managing Language Barriers in Health Care. Clin Pediatr. 2016;55(14):1318-1327. https://doi.org/10.1177%2F0009922816629760. https://doi.org/10.1177%2F0009922816629760 ABSTRACT