# Medical Interpreting in Primary Care: Design and Validation of a Replicable Training Program D. Mike Hardin Jr, MD¹ Jesús Andrés Osornio, MHA² José R. Peña III, DO¹ Esther Hur, PbD³ Karol J. Hardin, PbD³ ¹Waco Family Medicine – Institute, Waco, Texas ²Sam Houston State University, College of Osteopathic Medicine, Conroe, Texas ³Department of Modern Languages ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_0_Picture_3.jpeg) ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_0_Picture_4.jpeg) ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_0_Picture_5.jpeg) Conflicts of interest: authors report none. #### CORRESPONDING AUTHOR D. Mike Hardin Jr Waco Family Medicine – Institute 1600 Providence Dr Waco, TX 76707 mike.hardin@wacofamilymedicine.org #### **ABSTRACT** **PURPOSE** Language-concordant and professional interpreter-mediated care improve health outcomes, but clinics often lack resources to meet these needs. We developed and tested a replicable process to train heritage Spanish-speaking employees as qualified dual-role interpreters. **METHODS** Our interdisciplinary team conducted a single-group, pretest–post-test study in a community health center. Participants (137 individuals) completed a demographic survey, a self-assessment of Spanish proficiency, a formal oral proficiency test of general Spanish, a 40-hour online medical interpreter course, and pre- and post-training interpretation assessments. We used a multivariate regression analysis, Spearman's rank-order correlation, and paired *t*-tests to analyze the results. **RESULTS** Of 137 enrolled, 87 completed training and post-assessment. Heritage speakers had limited ability to predict their general Spanish proficiency ( $\beta$ = .14, P = .003; $\rho$ = .258, P = .003). No self-reported variables predicted baseline medical interpretation skills. After training, mean interpretation scores improved significantly (pretest 7.34 vs posttest 8.46; t(87) = 7.51, P < .001). Higher general oral proficiency predicted higher interpreting post-test scores ( $\beta$ = .31, P < .001; $\rho$ = .486, P < .001), and those with lower proficiency were more likely to drop out. Overall, 72% (63/87) of participants who completed training achieved qualified interpreter status. **CONCLUSIONS** An affordable, online training program can effectively prepare heritage Spanish-speaking clinic employees to be qualified interpreters. Clinics can use this approach to meet federal language access standards and address health disparities. Abstract also available in French, Spanish, and German. Ann Fam Med 2025;23:507-514. https://doi.org/10.1370/afm.250074 ### INTRODUCTION anguage barriers between patients and health care providers are a well-documented source of challenges and inadequate care,^1-3 in part due to the limited availability of bilingual physicians and interpreters.^4,5 More importantly, non–language-concordant care is associated with negative clinical outcomes^6-8 in contrast to the benefits seen with language-concordant care^1,9 and use of professional interpreters.^6,10,11 In the United States, over 1,400 community health centers care for 31.5 million Americans—nearly 10% of the US population. A core mission of community health centers is to bridge disparities such as cost of care, lack of insurance, and language barriers. While 8% of the US population is considered to have limited English proficiency, among the community health center population, 26% of patients are best served in a language other than English. Current national regulations require health care entities that receive federal remuneration¹⁶ to take "reasonable steps to provide meaningful access" to patients with limited English proficiency.¹⁷ They stipulate that interpreters should be "qualified,"¹⁸ defined as interpreters who are certified¹⁹ or have been assessed with a language proficiency assessment (regardless of certification status). Qualified interpreters must meet 3 standards²⁰: (1) adhere to generally accepted interpreter ethics principles; (2) demonstrate proficiency in spoken English and the target language; and (3) be able to interpret effectively and accurately. There is, however, no federal standard for assessing interpreter language proficiency, and training is not explicitly required.21 Two national certification bodies have developed a formal certification pathway for single-role professional interpreters.22,23 One of the required components is completion of a 40-hour interpreter training course focused on ethics and professional practices. There are many barriers to providing interpreters in the ambulatory setting, with cost being a principal concern.5,24 In most states, the expense for interpretation services is borne by the health care organization and is not reimbursed by insurance or governmental programs.19 The average cost of these services is \$2.00 to \$3.50 per minute for remote interpretation and \$150 per hour for in-person interpretation,19 a cost that can quickly exceed the average reimbursement per visit.5,25 These financial issues are magnified in community health centers which have a greater proportion of uninsured and underinsured patients, and up to 3-fold as many patients with limited English proficiency.13-15 A common strategy to meet interpretation needs in the ambulatory setting is the use of qualified bilingual speakers.18 One type of qualified bilingual speaker is a dual-role interpreter (ie, an assessed bilingual employee who interprets in addition to their primary job duties).5,26,27 Importantly, many ambulatory centers like community health centers have an untapped asset—heritage speakers.28 Heritage speakers are bilingual individuals who have a cultural connection with the heritage language but may not have formal education in that language.29,30 They are a heterogenous group,31 but due to their early exposure to the heritage language, they often have strong oral and aural skills, a solid conversational foundation, and a deeper understanding of pragmatic and sociolinguistic norms.29,32,33 Many heritage speakers have been cultural brokers and system navigators between their families and the local medical system, so they have the advantage of familiarity with the community34,35 and clinic-specific knowledge.36 They can readily build on existing knowledge to refine vocabulary, register, and accuracy.29,37 These factors make them well-suited for targeted training and valuable assets for interpretation in ambulatory care settings.38 Heritage speakers, however, may struggle with more specialized and formal language, resulting in difficulties when they encounter complex language demands in the workplace.33 This challenge may stem from a lack of formal education or limited familiarity with professional terminology in their heritage language.39 For example, heritage speaker medical staff may overestimate their language proficiency and underestimate their medical language limitations.40,41 A heritage speaker's unique bilingual skills do not necessarily include the ability to interpret in a medical setting,42 as medical interpretation is a learned skill.27 Considering the substantial need for medical interpretation in the ambulatory care setting, we investigated a strategy to leverage the unique skillset of employees who are heritage speakers in a cost-effective manner that could be replicated in other clinics. Strikingly, there is no published literature that comprehensively examines this strategy.43,44 We designed and studied a quality improvement project in a community health center to determine if a standardized, easily replicable, and cost-effective training process could improve medical interpretation skills and formally qualify dual-role heritage speaker interpreters. ## **METHODS** From October 2022 through June 2023, all employees who provided dual-role interpretation services in Spanish at a large community health center were required to participate in a medical interpretation quality improvement project. The project was funded by the American Rescue Plan Act of 2021, approved by the Ascension Providence Institutional Review Board, and designed by an interdisciplinary team of physicians and linguists. A summary of all testing instruments and training interventions is provided in **[Supplemental Table 1](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**. Participants completed an online demographic survey to determine their educational background, speaker classification (ie, native,45,46 heritage,29,31,37 or second language47), history of providing interpretation, and self-estimation of language and interpretation skills. The LinguaFolio Self-Assessment Grid48 was used for self-estimation of general oral Spanish proficiency. General oral proficiency in Spanish was assessed with a standardized oral proficiency interview-computer (OPIc),49 conducted by Language Testing International, and reported using the American Council on the Teaching of Foreign Languages (ACTFL) proficiency scale.50 To allow for statistical analysis, integer values were assigned to represent each textbased ACTFL level descriptor. Participants received a copy and explanation of their results. Subsequently, all subjects completed a preintervention assessment of their medical interpretation with the interactive voice response Medical Interpreter Test through ALTA Language Services, Inc.51 Results were reported on ALTA's 12-point proprietary interpretation result scale (**[Supplemental](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1) [Table 2](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**).52 Participants were blinded to their results. All participants who completed initial testing were enrolled in a 40-hour medical interpreter course through ALTA (*Breaking Boundaries in Healthcare*).53 The asynchronous online course covered the content required to begin obtaining national certification as a medical interpreter, while also providing remote coaching, teaching sessions, and optional Spanish-language interpretation practice modules (**[Supplemental](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1) [Table 1](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Participants received small financial incentives to meet project milestones and, as staffing permitted, work time to complete online training and testing. Following successful completion of the training intervention, participants completed a final requirement of the course, a formal medical interpretation test through ALTA53 comprised of a live, dual-rater assessment conducted by telephone. Results were reported on the same proprietary 12-point interpretation scale for comparison to the pre-intervention results from the interactive voice response interpretation test. **Table 1. General Spanish Proficiency: Self-Estimated and Assessed ACTFL Test Results (N=133a)** | ACTFL proficiency
scale (integer value) | Self
estimated,
No. (%) | Assessed
ACTFL,
No. (%) | | |--------------------------------------------|-------------------------------|-------------------------------|--| | Novice-Low (1) | 3 (2.3) | 0 (0.0) | | | Novice-Mid (2) | 1 (0.8) | 0 (0.0) | | | Novice-High (3) | 2 (1.5) | 0 (0.0) | | | Intermediate-Low (4) | 7 (5.3) | 2 (1.5) | | | Intermediate-Mid (5) | 3 (2.3) | 2 (1.5) | | | Intermediate-High (6) | 5 (3.8) | 13 (9.8) | | | Advanced-Low (7) | 18 (13.5) | 54 (40.6) | | | Advanced-Mid (8) | 18 (13.5) | 56 (42.1) | | | Advanced-High (9) | 34 (25.6) | 5 (3.8) | | | Superior (10) | 42 (31.6) | 1 (0.8) | | | Distinguished (11) | 0 (0.0) | 0 (0.0) | | ACTFL=American Council on the Teaching of Foreign Languages. Evaluators were unaware of the participants' prior pre-intervention assessment results. Participants scoring at or above the community health center's established threshold (ALTA interpreter scale level 8) were deemed qualified as interpreters and received a pay increase of \$1.50/hour, an approximately 8% raise. Quantitative data analysis was conducted using R version 4.4.1 (R Foundation for Statistical Computing).54 A multivariate regression analysis was performed to identify data correlations and a Spearman's rank-order correlation to assess the strength of the relationship. A paired *t*-test was conducted on the pre- and post-test results to determine the effect of the intervention. Qualitative data were obtained via an online survey and direct feedback from participants and were analyzed by the research team. ## **RESULTS** Of the initial 197 participants enrolled in the quality improvement project, 176 self-identified as providing interpretation at some point during their employment. Of these, only 137 held roles that required interpretation services and were thus eligible for the training intervention. Of the 137 participants who completed the initial assessment, 20 were removed from post-intervention analysis for logistical reasons (eg, no longer employed by the organization, did not start the training process), and 30 withdrew without completing the training and testing process. Commonly cited reasons for withdrawal were educational level (course content deemed too rigorous), social determinants (lack of home computer or high-speed internet), and employer-related issues (insufficient work time to complete training). Eighty-seven participants completed the survey, training, and all tests. The 30 participants who did not complete the training process or take the final test (non-completers) had lower general Spanish proficiency (OPIc) scores (mean = 6.83) than the 87 completers (mean=7.39, Welch t(52.5)=2.49, *P*=.017) with a moderate-to-large effect size (Cohen's *d*=0.60) (**[Supplemental Table 3](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Those with higher proficiency were more likely to complete the training (odds ratio [OR]=1.81; 95% CI, 1.18-2.89; *P*=.009) (**[Supplemental Table 3](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Demographic analysis of the eligible interpreters revealed that 96% (131/137) of the participants providing interpretation services were heritage Spanish speakers (**[Supplemental](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1) [Table 4](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Ninety-seven percent (133/137) of participants did not possess a bachelor's degree, and 69% (94/137) reported a general educational development or high school diploma as their highest education level (**[Supplemental Table 4](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Only 2% (3/137) of employees who were actively interpreting had ever received any interpreter training, and just 1 had completed an interpretation course that offered credit. Participants who provided interpretation were primarily clinical assistants (65%) or front desk/reception employees (34%) (**[Supplemental Table 5](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)**). Self-estimated and assessed general Spanish proficiencies are reported in **[Table 1](#page-2-0)**. Notably, 32%, (42/133) of participants self-estimated their general language proficiency as native, but only 1 of those tested at the ACTFL Superior level (near-native proficiency) and none tested at the Distinguished level (native proficiency).55 Multivariate regression analysis showed that self-reported variables did not correlate with formally assessed general Spanish proficiency (OPIc score), except for self-estimated **Table 2. Spearman's Rank Correlation: Self-Reported Variables vs Assessed Oral Proficiency and Medical Interpretation Test Results** | | | General proficiency
by OPIc score | | Medical interpretation
test result | | |----------------------------|------|--------------------------------------|---------|---------------------------------------|---------| | Variables | No.a | ρb | P value | ρb | P value | | Years interpreting | 134 | −0.015 | .860 | 0.034 | .693 | | Interpreting frequencyc | 137 | 0.107 | .211 | 0.004 | .963 | | Total interpreting volumed | 137 | 0.126 | .142 | 0.063 | .463 | | Self-estimated proficiency | 133 | 0.258 | .003 | 0.054 | .538 | OPIc=oral proficiency interview-computer. - Number varies due to partially completed survey responses. - b Spearman's rank-order correlation. - Amount of interpreted visits/day. - d Product of years interpreting and frequency interpreting. a Number differs from total in the intervention due to partially completed survey responses. general proficiency, which displayed a low correlation with assessed general proficiency (n=133; β=.14; 95% CI, 0.07-0.21; *P*=.003; ρ=.258; *P*=.003) (**[Table 2](#page-2-1)**, **[Figure 1](#page-3-0)**). Similarly, self-reported variables, including self-estimated proficiency, did not correlate with baseline medical interpretation test results (n=133; β=.09; 95% CI, –0.03 to 0.22; *P*=.15; ρ=.054; *P*=.538) (**[Table](#page-2-1) [2](#page-2-1)**, **[Figure 1](#page-3-0)**). A paired *t*-test revealed a statistically significant increase in medical interpretation scores from pretest (mean=7.34) to posttest (mean=8.46; t(87)=7.51; *P* <.001) **[\(Figure 2](#page-4-0)**). Regression analysis demonstrated that general oral proficiency (OPIc) scores predicted medical interpretation posttest scores (n=87; β=.31; 95% CI, 0.19-0.43; *P* <.001) with a low-moderate strength of correlation (ρ=.486; *P* <.001) (**[Figure 3](#page-4-1)**). Participants who scored below an ACTFL proficiency of intermediate-high did not pass the post-intervention medical interpretation test (**[Figure 4](#page-5-0)**). Of the 87 participants who took the test, 63 (72%) passed and qualified to be interpreters. ## **DISCUSSION** The national need for qualified interpreters cannot be met by utilizing remote or in-person professional interpreters alone, especially at the community and outpatient level where most health care occurs,56,57 and there are often limited resources. This study evaluates a first step to another solution for busy, com- munity-based practices: formally qualifying heritage language speakers as dual-role interpreters. Heritage speakers bring unique benefits and limitations. This study confirms prior research that bilingual individuals have limited ability to predict their language proficiency,58 demonstrated by a low, but statistically significant (*P*=.003) Spearman's rank correlation. No other self-reported factors (eg, prior interpreting experience) predicted their general Spanish proficiency or medical interpreting ability. This result stresses a crucial point for physicians and health care administrators—they cannot rely on an employee's self-reported language ability. Medical language proficiency for interpreting must be formally assessed as required by federal regulations. Before the study, we hypothesized that participants should have a Spanish proficiency of Advanced-Mid or **Figure 1. Regression Analyses of Self-Estimated Proficiency vs OPIc and Pre-Intervention MIT Scores (N=133)** 1 2 3 4 5 6 7 8 9 10 **OPIc score Self-estimated prociency** 0 1 3 2 45678 9 10 11 0 1 2 3 4 5 6 7 8 9 10 **MIT score, pre-intervention Self-estimated pro ciency** 0 1 3 2 4 5678 9 10 11 Advanced-High to successfully qualify as interpreters after training, but the participants' average general proficiency results were only Advanced-Low. The study design intentionally allowed those with a lower general Spanish proficiency to continue through the entire training and testing process to determine if these speakers could be trained up to interpreter status through a standardized intervention. This design also allowed for determination of a proficiency threshold, below which staff should not be considered for training. Since participants who scored below an ACTFL proficiency of Intermediate-High did not pass the post-intervention medical interpretation test at the community health center's qualifying score, the organization set a minimum Spanish proficiency (Intermediate-High) required to begin MIT=medical interpretation test; OPIc=oral proficiency interview-computer. the training process. Establishing a qualifying proficiency score will allow the organization to focus its resources on those with the highest chance of succeeding in the future. The issue of interpreting proficiency is related but differs from that of general language proficiency. Federal standards specify criteria to qualify interpreters, but they do not set a required language proficiency level. Various testing and professional bodies have detailed recommendations based on their proprietary scales and testing.^22,23 We suggest that ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_4_Figure_3.jpeg) the standard score to qualify as an interpreter should vary by setting, based on patient acuity, volume, and on-theground realities. For this study in a community health center, we selected an interpreter qualifying score of 8 (ALTA Interpretation Score), just below that recommended by the testing body (score of 9). Using that cutoff, 72% (63/87) of participants who completed training qualified as interpreters for the organization (Supplemental Figure 1). The average cost of training and testing in this quality improvement project was \$500 per employee. Various factors affected participant attrition. Employees in this study filled clinic roles that require less education, are lower paid, and have an inherently high turnover rate. Staff reported that socioeconomic factors and course rigor increased attrition. Additionally, pre-intervention general proficiency testing revealed an unanticipated high number of lower-proficiency speakers in the cohort. Subsequent results showed that lower proficiency scores were associated with a higher rate of course non-completion. The barriers identified by participants, including educational and social factors, were unanticipated, yet similar to those faced by community health center patients. Future training efforts should focus on addressing modifiable barriers to enhance completion rates. The process outlined in this study—assessed proficiency in the target language (ie, Spanish), interpreter training and testing, and role-specific English proficiency—meets the federal requirements to designate qualified interpreters. The following steps outline the practical application of our results: - (1) Develop a relationship with a reliable testing and training agency to help guide test selection and overall process. - (2) Identify Spanish-speaking employees in roles eligible for dual-role interpreter status. - (3) Determine a general Spanish proficiency level required to begin training (eg, Intermediate-High was used in our setting). - (4) Perform a general Spanish proficiency test. - (5) For employees with a qualifying general proficiency score: - (a) Enroll in a medical interpreter training course; - (b) Set a score threshold to qualify as a medical interpreter (eg, ALTA Level 8 was used in our setting) based on interpretation needs, staffing levels, and budgetary constraints; and - (c) At course completion, perform a medical interpretation test (eg, can be a final component of the course). ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_4_Figure_18.jpeg) This study focused on both the feasibility and validity of a novel process to specifically train dual-role heritage speaker interpreters. Future research could examine the impact of this approach on clinical outcomes, including communication analysis (eg, errors in communication, rapport, brokering, adherence to interpreter ethics), patient and provider satisfaction, and improvements in medication or treatment adherence, patient follow-up, and disease-specific surrogate markers (eg, HbA1C, blood pressure). There are several limitations to this study. Prior linguistic research has shown that standardized proficiency tests may not accurately assess heritage speaker proficiency as well as they assess native or second language speakers.59-61 Additionally, participation in this quality improvement project was required. While this requirement maximized enrollment, it may have increased attrition. Allowing internally motivated staff the option to train as interpreters may result in less attrition. The pre- and post-tests utilized the same proficiency scale and were comparable in content and methodology but were not identical tests; this difference could skew the measured improvement. At the same time, using comparable tests avoided the positive test effect seen in language research with identical tests.62,63 Finally, the use of full integers to represent the level descriptors of language proficiencies may not accurately represent the nuanced degrees of difference between various proficiency levels. The nationwide demand for qualified medical interpreters at the community level is high. This study evaluated an innovative approach to address this need, leveraging the unique linguistic and cultural strengths of heritage speakers and validating a cost-effective, replicable training process to qualify medical interpreters. This approach may be particularly beneficial in ambulatory settings where demand for remote and professional in-person interpretation services may be a financial burden. The provision of language-concordant care is fundamentally a matter of health equity. Given the high cost and limited number of bilingual clinicians, medical organizations should leverage existing heritage speaker staff, accessible training resources, and appropriate language tests to address this disparity. ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_5_Figure_5.jpeg) ## **[Read or post commentaries in response to this article.](https://www.annfammed.org/content/23/6/507/tab-e-letters)** **Key words:** community health centers; healthcare disparities; heritage speakers; interpreter training; limited English proficiency; medical interpreting; self-assessment; staff development Submitted February 1, 2025; submitted, revised, May 20, 2025; accepted June 3, 2025. ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_5_Figure_9.jpeg) ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_5_Figure_10.jpeg) ACTFL=American Council on the Teaching of Foreign Languages; Adv=advanced; Int=intermediate; MIT=medical interpretation test. Organization-determined passing score (Level 8 on ALTA's Interpretation Performance Levels) to qualify as an interpreter. **Funding support:** Financial support for the project provided by the American Rescue Plan Act of 2021. **Previous presentations**: Paper presented at 7th International Symposium on Languages for Specific Purposes & Centers for Business Education and Research Business Language Conference; May 3, 2024; Washington, DC. Posters presented at 16th Annual Health Research Forum; April 23, 2024; Waco, Texas, and at 15th Annual Health Research Forum; April 18, 2023; Waco, Texas. **Acknowledgments:** The authors wish to acknowledge Bradley Thompson, MS and Rodney Sturdivant, PhD for their assistance in statistical analysis. They were not compensated for this work. We also thank the employees of the community health center who generously gave of their time to participate in the study. ![](https://assets.reachrx.ai/images/10.1370%E2%98%8Dafm.250074/_page_5_Picture_16.jpeg) **[Supplemental materials](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC1)** **[Spanish](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC4)**, **[French](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC3)**, and **[German](https://www.annfammed.org/lookup/suppl/doi:10.1370/afm.250074/-/DC5)** abstract translations ## **References** - 1. Diamond L, Izquierdo K, Canfield D, Matsoukas K, Gany F. A systematic review of the impact of patient-physician non-English language concordance on quality of care and outcomes. *J Gen Intern Med*. 2019;34(8):1591-1606. doi: [10.1007/s11606-019-04847-5](http://doi.org/10.1007/s11606-019-04847-5) - 2. Flores G. 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