Communication is key: a critical analysis of Spanish language policies and ideologies in healthcare settings in the United States

Effective communication is a vital component in providing quality healthcare. Communication between patients and their healthcare providers has been shown to have substantial effects on health outcomes. According to the 2012 U.S Census 5% of the U.S population who identifies as Hispanic or Latino reports having a low English proficiency (LEP). Utah, along with many states with a sizeable Hispanic/Latino population, has only a small fraction of healthcare professionals that speak Spanish with sufficient proficiency for effective communication with LEP Spanish-speaking patients. It is the goal of this project to first, demonstrate how pertinent effective communication between Spanish speaking patients and healthcare providers is to patient satisfaction and health outcomes, and secondly, to analyze health care policies addressing language services in healthcare settings and underlying ideologies which may be influencing the implementation of said policies in various regions of the U.S. The research in this project focuses on 1) analyzes policies that address language services in healthcare settings across the U.S. 2) reviews literature that discusses the ways certain biases may affect language policies in the U.S. and 3) reports the results of an anonymous questionnaire answered by patients and healthcare providers on these issues. The questionnaire was distributed to patients and providers of a free public clinic in Salt Lake City, Utah. The questionnaire was tailored for each group to provide insight into the perceived effectiveness of communication from their respective perspectives. The literary review shows that federal and state policies regarding language services in healthcare in the U.S are frequently inconsistent, and ill-defined. The state policies vary greatly between one another, as well as between varying healthcare institutions. The U.S healthcare system is presently being reexamined and remodeled. As the Hispanic/Latino demographic in the U.S. continues to grow, it is imperative that Spanish language policies are likewise reexamined. Recognizing the potential biases influencing the implementation of these policies will provide insight into the rationale behind existing policies, and present novel approaches to be taken in the future to better communication, and improve healthcare outcomes for LEP Spanish-speaking patients.

COMMUNICATION IS KEY: A CRITICAL ANALYSIS OF SPANISH LANGUAGE POLICIES AND IDEOLOGIES IN HEALTHCARE SETTINGS IN THE UNITED STATES by Natalie Meadows A Senior Honors Thesis Submitted to the Faculty of The University of Utah In Partial Fulfillment of the Requirements for the Honors Degree in Bachelor of Arts In Department of Languages and Literature Approved: ______________________________ Dr. Sheri Anderson-Gutierrez Thesis Faculty Supervisor _____________________________ Dr. Katharina Gerstenberger Chair, Department of Languages and Literature _______________________________ Dr. Eric Laursen Honors Faculty Advisor, Department of Languages and Literature _____________________________ Sylvia D. Torti, PhD Dean, Honors College August 2014 Copyright © 2014 All Rights Reserved ABSTRACT Effective communication is a vital component in providing quality healthcare. Communication between patients and their healthcare providers has been shown to have substantial effects on health outcomes. According to the 2012 U.S Census 5% of the U.S population who identifies as Hispanic or Latino reports having a low English proficiency (LEP). Utah, along with many states with a sizeable Hispanic/Latino population, has only a small fraction of healthcare professionals that speak Spanish with sufficient proficiency for effective communication with LEP Spanish-speaking patients. It is the goal of this project to first, demonstrate how pertinent effective communication between Spanish speaking patients and healthcare providers is to patient satisfaction and health outcomes, and secondly, to analyze health care policies addressing language services in healthcare settings and underlying ideologies which may be influencing the implementation of said policies in various regions of the U.S. The research in this project focuses on 1) analyzes policies that address language services in healthcare settings across the U.S. 2) reviews literature that discusses the ways certain biases may affect language policies in the U.S. and 3) reports the results of an anonymous questionnaire answered by patients and healthcare providers on these issues. The questionnaire was distributed to patients and providers of a free public clinic in Salt Lake City, Utah. The questionnaire was tailored for each group to provide insight into the perceived effectiveness of communication from their respective perspectives. The literary review shows that federal and state policies regarding language services in healthcare in the U.S are frequently inconsistent, and ill-defined. The state policies vary greatly between one another, as well as between varying healthcare institutions. The U.S healthcare ii system is presently being reexamined and remodeled. As the Hispanic/Latino demographic in the U.S. continues to grow, it is imperative that Spanish language policies are likewise reexamined. Recognizing the potential biases influencing the implementation of these policies will provide insight into the rationale behind existing policies, and present novel approaches to be taken in the future to better communication, and improve healthcare outcomes for LEP Spanish-speaking patients. iii TABLE OF CONTENTS ABSTRACT ii 0.0 PREFACE 1 1.0 INTRODUCTION 1 2.0 LANGUAGE POLICY IN THE UNITED STATES 3 2.1 FEDERAL POLICY HISTORY 5 2.2 STATE POLICY HISTORY 6 3.0 PREVELANT IDEOLOGIES IN THE U.S AND THEIR INFLUENCE ON LANGUAGE POLICY 9 4.0 RELATING LANGUAGE POLICY TO HEALTH CARE 12 4.1 CONSIDERATIONS FOR HEALTH CARE ORGANIZATIONS AND PROVIDERS 18 4.2 LANGUAGE AND EFFECTS ON PATIENT CARE 26 5.0 LOCAL STUDY RELATING LANGUAGE SERVICES AND PATIENT SATISFACTION 28 6.0 LANGUAGE POLICY AND THE AFFORDABLE CARE ACT 30 7.0 CONCLUSION 33 REFERENCES 35 iv 0.0 PREFACE In 2012, while living in a small western Wyoming community, I found myself in a surprising situation, the likes of which I never expected myself to be in until that day. I was sitting alone in an emergency room, in the town grew up in, waiting for an interpreter. As a 20 year old Caucasian female who had lived all the years of my life in the United States I never once experienced an occasion such as this. Although I grew up in a community with a large Spanish-speaking population, and often observed the difficulties experienced by individuals with low English proficiency, my personal dealings were never deeply affected by this diverse demographic nor did I personally need assistance with communication. I learned, and developed a genuine love for, the Spanish language through school and various life experiences; and at this time, I chose to use my skills in participating in a community anthrax drill in my hometown. As a Spanish-speaking patient actor, I was given the role of a young pregnant woman showing severe symptoms of anthrax exposure. However, due to my artificial language barrier, I was triaged incorrectly and ultimately waited in the emergency room for an interpreter for three hours. Had I been an actual patient, the situation could have been fatal. For me, this day was a sad enlightenment that changes needed to be made, not only in my hometown community, but in countless other communities and cities all over the United States. 1.0 INTRODUCTION The U.S has never been a monolingual country. While English is the perceived socially accepted language used primarily in lieu of a national language, this designation is merely an informal representation of the language identity for peoples in the U.S. Legally, it holds no merit. As a country the U.S has no official language, although 17 bills introduced to Congress 1 tried to make English the official language since 1981 (Del Valle, 2003, p. 58). None of these have passed beyond the Senate. However, several states designed and implemented several versions of language policy. These laws may be ‘Official English’ laws, in which English is protected or formally declared the language of the government, and does not make any direct attempts to target non-English language usage. ‘English-Only’ legislation, however, tends to be supported by those who believe that minority, or non-English languages, have no place in U.S society. Image 1 shows the geographical distribution of the Spanish-speaking population in the continental U.S (US Census, 2012) This paper will examine several facets of language policy, with particular attention placed on its place in and effects on health care in the United States. As Spanish is also the most spoken minority language in the U.S, particular attention will also be directed at Spanish and Spanish-speakers in the U.S. Over 38 million people in the U.S speak Spanish, a figure which establishes the U.S as the 3rd largest Spanish speaking population in the world. According to U.S Census Data, approximately half of the Spanish-speaking population is native-born, while a majority of other non-English speaking groups are foreign-born (2012). This figure 2 demonstrates that Spanish language is persisting across generations in the U.S, and that immigration policy will not completely address the issue. Image 2 shows the geographical distribution of the LEP Spanishspeaking population in the continental U.S (US Census, 2012) Of these 38 million Spanish speakers, it is estimated that 16 million have low English proficiency (LEP). The term Limited English Proficient (LEP) refers to any person ages 5 and older who reported speaking English less than ‘very well’ as classified by the U.S. Census Bureau (Whatley 2013). Much of this population encounters difficulties, due to language barriers, in their everyday lives here in the U.S. These barriers can have devastating effect on individuals and families, particularly encountered in healthcare settings and situations. As the Hispanic/Latino demographic in the U.S. continues to grow, it is critical that Spanish language policies are likewise reexamined. Recognizing the potential biases influencing the implementation of these policies will provide insight into the rationale behind existing policies, and present novel approaches for the future to better communication, and improve healthcare outcomes for LEP Spanish-speaking patients. 2.0 LANGUAGE POLICY IN THE UNITED STATES 3 Language is among the most omnipresent and pervasive features of human life. Language not only influences individual identity and personal interactions, but it is the very construct upon which societies are built. The functions of language as outlined by Thom Huebner in Sociopolitical Perspectives on Language Policy and Planning in the U.S. include: social expression of identity and group membership, political power and economic dominance and inequity, and an entity that creates reality and controls matter. Language is likewise a matter of academic value in terms of syntax relating to group membership and dynamics, lexicon being associated with experience and metaphors and other literary devices providing insight into the conceptual way information is transmitted from person to person and within groups and societies (Huebner, 1999). As such, legal policies that address language are inseparably tied to issues regarding race and ethnic identity, nationality and patriotism, ethics, linguistics. Since its inception, the United States has always held a unique position in regards to language. Even before European colonization, this land had been the home to populations speaking a wide variety of native languages. Spanish was, in reality, the first European language to inhabit the area. The early history of language in the Americas is less a story of political struggles in regards to language, but more so a tale of linguistic and cultural repression and domination. As the Anglo population, which would eventually form the base majority of the population involved in the American Revolution, migrated to the continent in large numbers, a variety of European languages were actively spoken in the land. Although, the founders of the United States acknowledged the potential need for a standardized language, a majority supported multilingual communities and maintained the belief that language was not a matter of official regulation (Piat, 1990). 4 Into the 20th century, America continued to reinforce its identity by encouraging, and working to provide protocols for immigration. However, the incredible masses teeming into the country, with variable languages and backgrounds, did elicit feelings of resentment for many Americans. “Little can make a country as uncomfortable as a significant rise in immigration that may challenge a nation’s conception of itself (Del Valle, 2003, p. 54).” The U.S moved into an era in which language in the U.S was being scrutinized and tried more than ever before. The following sections discuss legal movements, on both the federal and state levels, which affected perspectives and policies regarding language in the United States. 2.1 FEDERAL POLICY HISTORY Federally, most legal decisions regarding language have been combated through the judicial branch. Many significant cases occurred during the WWI and WWII periods, because fear and distrust of what came to be termed as ‘foreigners’ was at an all-time high (Piat, 1990). “The use of foreign languages was not only unpatriotic, but something apparently to be feared- it reflected a mind and an identity unknown and perhaps unknowable: a fear born of a deep sense of vulnerability that what was spoken in a foreign language could not be benign but must be mysterious, secretive and cunning (Del Valle 2003, p 36).” One of the first prominent cases that surfaced during this period was Meyer v. Nebraska in 1919. The case was in response to the Nebraska statute that declared it illegal for educational instruction to be in German. “To allow the children of foreigners… to be taught from early childhood the language of the country of their parents was to rear them so that they will always think in that language, and, as a consequence, naturally inculcate in them the ideas and sentiments foreign to the best interests of this country (Del Valle, p. 38, 2003). The case was 5 ultimately appealed to the U.S Supreme court. At that point, the plaintiff’s primary assertion to the court was that individuals have a right to educate their children in the language of their choice. The court ruled that banning instruction in schools in a non-English language violated the Due Process Clause of the 14th Amendment which states: “No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws” (Legal Information Institute, n.d) However, it should be noted that this ruling fundamentally addressed parent’s rights, the right a parent has to elect a language of instruction for their children; and did not specifically address the rights of a language minority. 2.2 STATE POLICY HISTORY Generally, there are two types of laws concerning language implemented by individual States. “Official English” laws do not target nor affect the private usage of any minority language, but rather dictates that English is the language to be used in social and civic life in the U.S. However, “English-Only” laws more directly attempts to reduce, and perhaps eliminate the usage of minority languages in the U.S. from the public sphere. Nationally, attempts to pass official- English or English-Only laws have been unsuccessful. Individual states have been more successful in passing language legislation than any attempts to pass federal legislation. Some states, such as California, sought to protect language rights through political measures. Dating back to the Treaty of Guadalupe Hidalgo, through which the U.S took legal possession of the California territory, ‘linguistic tolerance’ has long 6 been a matter of concern for the state. The 1849 California Constitution officially decreed California a bilingual state for both English and Spanish. The statute requiring the translation of laws into Spanish was removed 29 years later, and after a century passed Proposition 63 in 1986 did make English the only official language of the state (Del Valle, 2003). Issues regarding the Spanish language drew into question, and delayed the ratification of, New Mexico’s statehood. At this time there was great hesitation by federal government to grant New Mexico statehood due to vast Spanish speaking population, outnumbering English speakers, as well as use of Spanish in public affairs and documents i.e. schools and courts (Del Valle 2003). Some people felt that “‘the people of New Mexico are not Americans…they speak a foreign language’” (Del Valle p. 15, 2003), demonstrating the fundamental connection between national identity and language. New Mexico did eventually achieve statehood in 1912, one it was determined that the population had properly ‘assimilated’. As a state, New Mexico did try to maintain to its linguistic traditions for a time after statehood was granted, and editions of the laws were printed in both English and Spanish until 1949 (Del Valle 2003). The state of Arizona has also addressed language issues through legislation. In 1988, Proposition 106 was brought to the table in Arizona State, sponsored by the English-only group Arizonans for Official English. This initiative to amend Arizona’s constitution promised to work to remove non-English languages from state and local government offices, documents and employees. The amendment passed with 50.5% in that year’s general elections, and became Article XXVIII in the Arizona state constitution (Del Valle 2003). The law even expressly defends English in the 3rd section, part B: “A person shall not be discriminated against or penalized in any way because the person uses or attempts to use English in public or private communication” (Arizona State Legislature). The amendment, particularly the portions 7 addressing government employee usage of non-English was loosely interpreted, and multiple litigations have significantly reduced enforcement of the amendment in Arizona at any level. Although, government documents continue to only be made available in English. Wyoming provides an example of document centric English-only state legislation. The law states that English is the designated official language of Wyoming, and that unless otherwise “provided by law, no state agency or political subdivision of the state shall be required to provide any documents, information, literature or other written materials in any language other than English (Del Valle, p. 70).” However, the does law explicitly states in part b that, “agenc[ies] or political subdivision[s] may act in a language other than English… to provide information orally to individuals in the course of delivering services to the general public.” Wyoming’s law is an example of ‘Official English’ legislation, since its aim is primarily to establish English as the official language of the government, but does not directly limit non-governmental minority language usage. In November 2000, Initiative A the “English as the official language of Utah” law, passed with 67% approval in the state of Utah (Ballotpedia, 2013). Initiative A was crafted to bypass the issues that significantly reduced the potency of Arizona’s English-only law. “Nothing in this section affects the ability of government employees, private businesses, non-profit organizations, or private individuals to exercise their rights under: (a) the First Amendment of the United States Constitution (ACLU)” The law decrees that English is the sole language of the government. Additionally, the government appointed the State Board of Regents and State Board of Education to be in charge of rules regarding foreign language use in public and higher education in the state of Utah, with the “‘provision that they promote non-English speaking 8 children and adults to become able to read, write and understand English… quickly’” (Del Valle, p. 76). All official documents, transactions, proceedings etc. representing the state are likewise required to be conducted in English. However, a court hearing in 2001 issued a ruling that limited much of the law. According to the ruling the law cannot prohibit government employees and officials from using any non-English language, and that essential services such as driver’s license exams must be available in languages other than English. Likewise, Utah officials including the Attorney General swore to thoroughly investigate any cases in which the government may be denying equal access to government processes, programs and services based in misinterpreting the law (ACLU). Two topics which have in recent queued much of the debate and language policy legislation movement have been bilingual education and the translation of government documents such as voting ballots. This is particularly true specifically in regards to Spanish bilingualism in the US (Del Valle 2003). Since 1981, 17 bills have been put through the house trying to make English the official US language. All of which have not passed. There are several examples of supposed justification for legislators to support English-only movement. For one, it is said that by declaring English the official language immigrants will be more motivated to learn English than they are presently. Another, more defense oriented example, is that unless English is declared the official language, the nation’s unity will be threatened by the ethnic separation which will inevitably follow continued condoning of the present linguistic divisions (Del Valle 2003). 9 3.0 PREVALENT IDEOLOGIES IN THE U.S AND THEIR INFLUENCE ON LANGUAGE POLICY Language policies tend to be ad hoc responses to national and local needs, or political pressure (Huebner). This trend verifies, or at least exemplifies the undeniable relationship between language, politics, and society, and that formulating language policy has continually been reactive process. By gaining a better and more complete understanding of the underlying ideologies and assumptions made within our society can help us move away from reactive type legislation to proactive legislation regarding language policy in the United States. In using this approach seeing the impact that policies, which are derived from dominant language ideology may indeed become a more natural, and contemplative process. Ideologies are systems through which peoples and groups compartmentalize and idealize their expectations in certain situations. Being that language is such an integral aspect of humanity, there are several ideologies that generate biases that have been shown to be influential in regards to language policy and opinion. In the U.S, those who ascribe to the dominant language ideology believe monolingualism to be the ‘ideal’ condition. Language diversity is seen as a disruption, which moves society away from the ideal and into an unbalanced state. Language, specifically the dominant language, is associated with patriotism and, in the case of the United States, ‘Americanism’ (Wiley, 1996). This ideology contemporarily prevails not only in anglophone countries such as the United States, and Australia, but also in countries such as Belgium, where since and throughout the 20th century there has been an active movement to eliminate Dutch-French multilingualism in the country, transitioning to a monolingual Dutch society (Caluwé, 2012). 10 The prominent German sociolinguist, Heinz Kloss, outlined several assumptions that tend to be made within monolingual language ideology. 1.) Minorities should surrender native language rights in exchange for inclusion in the receiving society. 2.) Immigrants will prosper more in their new society, than they would have in their countries of origin. 3.) Maintenance of native language and culture is a practice of self-elected isolation, which leads to cultural deficiencies or lag in these populations. 4.) Endorsing and sustaining a minority language will inevitable be a dispersive force, and negatively affect national coherence. And as such, complete linguistic assimilation of migrating peoples is a must in order to preserve national unity (Wiley, 1996). Dr. Rosina Lippi believes that within the dominant standard English ideology in the U.S, which holds strong bias favoring a homogenous and idealized version of English, the ‘communicative burden… rests solely with the speaker.’ However, she contests, in order to truly understand the relationship between linguistic interactions and social interactions, one must first acknowledge that communication is a “‘two-way street’” which “‘involves not only communicative competence on the part of the speaker, but also goodwill on the part of the listener’” (Wiley p. 517, 1996). Within this understanding, is the reality that in instances when the listener maintains a prejudice against the speaker they, “‘cannot hear what the person has to say because accent, as a mirror of social identity, and a litmus test for exclusion, is more important’” Wiley p. 517, 1996). Any supposed deficiencies then, are seen to be the fault of the speaker, as opposed to a shortfall within the societal system. Thus there is a tendency to ‘blame the victim’, which is to say to place the fault in communication on the speakers non-standard usage of English. Communication is hindered because of the speakers so-called ‘inadequacies’ and thus it seems fit to “ascribe a deficit status to them (Wiley p. 517, 1996).” 11 On a large scale these sorts of common interactions and outcomes hinder the social mobility, educational achievement and even self-perception and identity of non-standard English speakers. Individual’s, at times, would rather be viewed as ignorant non-English speakers, than an insufficient ESL (English as a second language) speaker. Thus, this phenomenon in and of itself can impede upon a minority language speakers desire and motivation to invest time into learning English. The intensity of external factors such as this may diminish the overall value of the investment required to become a functionally competent in a new language (Grin, 2003). The Standard English ideology holds to the idea that the U.S can be, and should be, moving towards status as nation in which there is almost complete linguistic hegemony. Those groups that are not ‘conforming’ to this idea are held responsible for not ‘progressing’, and will simply have to deal with the consequences. However, this viewpoint is extensively simpleminded. Recognizing that both the perceived status the dominant group applies to English learners, and the treatment of the learners by the dominant group has significant effects on learners attitudes toward the dominant language and culture may provide a more realistic basis upon which these issues can be addressed. 4.0 RELATING LANGUAGE POLICY TO HEALTH CARE In economic theory there is an occurrence known as ‘market failure’ in which the market itself is not sufficient in producing or supplying an appropriate amount of a given good or service (Grin, 2003). Any given language itself can be a considered a distinct form of currency within this theoretical market. It may be operating independently in a market environment, such as a particular community or society, or may be competing against other forms of language currencies within that market. Hence, when considering language from this perspective a market 12 failure can occur when the goods, or services, available through use of this ‘language currency’ insufficiently meet market demand. Causes for market failure that are particularly applicable to this analogy may include: high transaction costs that may restrain market agents from doing something that may one day be economically beneficial, and the presence of external factors where dynamic behavioral interactions between agents may adversely (or favorably) affect the production or availability of goods and services (Grin, 2003). External factors undeniably play a huge role in these ‘linguistic markets.’ Dominant ideologies, and the underlying beliefs and assumptions of which they are comprised, has a significant effect on the availability and extent of commodities available to users, or speakers, of any given language, whether it be the majority or minority language in a certain environment. Economist Francois Grin (2003) asserts that in cases of market failure in a free market system, government intervention is required in order to modify behavior and improve the welfare available to members of an underserved linguistic environment. The 1974 Supreme Court hearing of Lau v. Nichols brought legal attention to this idea of market failure occurring in regards to services being provided to speakers a non-English language. Special attention was directed to Title VI of the Civil Rights Act which states: “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance” (Legal Information Institute, n.d). In the eyes of the Supreme Court, discrimination by federal agencies on the grounds of language is equivalent to discrimination based on national origin. These rulings apply broadly across all federal agencies, including those within the Department of Public Health and Human Services 13 (DHHS). Services that are federally funded through this department must comply with Title VI; these include programs such as Medicare, Medicaid, State Children’s Health Insurance programs, CDC monies and NIH grants etc. (Chen 2007). If a hospital, clinic or other healthcare establishment, at any point, accepts funds from programs funded by the DHHS, then they are held within the jurisdiction that they must provide proper resources to LEP individuals, so that no patient is excluded from receiving any benefits of these services (Chen 2007). Should a federal agency be accused of noncompliance with Title VI by the DHHS, only those funds directed to the particular program or activity that is out of compliance could be terminated. Even in states where English-only legislation is in place, if federal funds are being appropriated to an institution they are still subject to non-discrimination requirements, including those addressing services to LEP individuals (Guidelines 2004). In 2000, President Clinton’s drew particular attention to the application of Title VI, and the ways in which it pertains to the rights and protections of LEP individual through Executive Order 13166 (Chen, 2007). This prompted the DHHS Civil Rights office to issue a substantial set of guidelines to healthcare institutions, in order to help them to know how to comply with Title VI and, more importantly, to help meet the needs of the LEP population. The DHHS has since released several sets of guidelines of this sort, the most recent revision released in 2004. It should be noted that, “the policy guidance is not a regulation but rather a guide. Title VI and its implementing regulations require that recipients take reasonable steps to ensure meaningful access by LEP persons. This guidance provides an analytical framework that recipients may use to determine how best to comply with statutory and regulatory obligations to provide meaningful access to the benefits, services, information, and other important portions of 14 their programs and activities for individuals who are limited English proficient” (Guidelines, 2004). Contained within this guide is a list of four factors that individual institutions can use to assess and determine the extent to which services for LEP persons should be provided: (1) The number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee. Recommended resources institutions can to consult during this assessment includes census data for the area for which the institution provides services, community agencies, schools, religious organizations, legal aid entities etc. The guide also recommends that institutions personally examine prior experiences in which language services were needed, or could have assisted in improving quality of care. (2) The frequency with which LEP individuals come in contact with the program If LEP patients are seen daily, services should be more extensive than if LEP patients are seen only on a bi-monthly basis. In this step it is also necessary to consider the primary language spoken by LEP individuals that utilize health services. For example, the magnitude and depth of resources that should be available in Arabic may differ greatly from those available in Mandarin Chinese if the Arabic-speaking patient population is less that 1% and the Mandarin-speaking population is 12%. It is noted in Guidelines that as the language services and resources provided increase, the frequency with which LEP individuals receive health care from that institution may increase, and in this case services would need to expand in order to continue to meet the needs of the patients. (3) The nature and importance of the program, activity, or service provided by the program to people's lives. 15 Chen notes that “given the nature and importance of healthcare services, healthcare providers have a special obligation to ensure language access for their patients” (2007). In regards to services which may be provided by healthcare institutions and providers in situations which are urgent and potentially life-threatening, in an emergency department for example, services should be readily available and able to produce immediate communication results. In less critical cases, such as informing patients about diets and food choices which are conducive for those with diabetes, having written information available in the language may be considered adequate. Any form of obtaining consent, however, is always considered important, and whether it is verbal or written, institutions must verify that the patient understands what he/she is consenting to by always utilizing interpretation services or translated documents. (4) The resources available to the grantee/recipient and costs Of course, economic considerations must be taken into account when determine what language services to offer. “Economics constantly reminds us of limitations – more precisely, of the fact that resources are limited, and that this imposes constraints on human action (Grin, 2003, p.6). Larger health care providers do have more resources which can be directed towards LEP services, when compared to smaller entities such as non-profit clinics. However, this factor is entirely interrelated with the other three factors, and although important, should not be the determinant in whether or not sufficient language services are offered to patients. In his essay Language Planning and Economics, Grin (2003) states that the “demographic size of a language community is likely to stimulate aggregate demand for language-specific goods and services consumed by that community. “From an economic perspective, there are two levels through 16 which language policy and services can be assessed and taken into consideration. Firstly, from an allocative perspective an institution must be concerned with the “aggregate welfare”, or the overall effect of the manner in which resources are allocated. Secondly, the distributive perspective focuses more substantially on the gains and losses experienced by certain groups as a product of resource distribution (Grin, 2003). Particularly true to healthcare organizations and institutions, is both the distinction and overlap that exists between ‘effectiveness’ in terms of making a difference, and ‘costeffectiveness’. In using these terms, cost-effectiveness is clearly the more quantitative measure, while effectiveness is more qualitative, and perhaps the more substantive, measurement. Overall effectiveness should be calculable by dividing total outcome by total cost. The manner in which costs and benefits are tallied is of course highly variable and subjective, but on the whole this method provides a framework through which healthcare providers can assess true costs, weighed against true benefits. Despite this apparent multitude of federal legislation protecting rights of LEP individuals in the U.S, Dr. Alice Chen of the University of California San Francisco (UCSF) and her collaborators acknowledge that the application, enforcement of this statute is limited at best (2007). She describes the implementations as a “patchwork of legal obligations which vary from state to state, from language to language, condition to condition, and from institution to institution… [these] individual laws vary tremendously in scope and impact, and together leave many important areas unprotected. Many focus exclusively on patient education, notification, or informed consent; some also target a specific health care setting, medical condition, or language” (2007, p. 363-4). 17 Sometimes these laws are exceptionally specific, and are may be reflective of the dominant moral or social agenda of the community. The state of Georgia serves as an example of this, as there are no state laws requiring any form of interpretation services for general health care, but it is required by law that a woman is informed of the risks associated with an abortion by means of a translator if she has a low English proficiency (Perkins, 2006). Of course, there are examples when specificity in state language policy, coupled with general health care language interpretation services, creates exceptional opportunities for increasing the quality of healthcare for language minority groups. In Illinois, through the Department of Aging, providers and senior citizens are supplied with a pamphlet in both English and Spanish that helps physicians, pharmacists and patients to keep track of prescribed medications and to help patients to adhere to the directions for proper use of various medications (Perkins, 2006). There also instances in which states have worked to significantly expand language legislation. As of 2009, California now requires that all privately managed health care plans and individual and group insurers provide clients with access to translated versions the necessary health care related materials (Chen, 2007). 4.1 CONSIDERATIONS FOR HEALTHCARE PROVIDERS AND ORGANIZATIONS Considerations for healthcare providers Legislation regarding language policy and LEP patient rights can, and has, also been addressed on the front of a healthcare provider’s duty and responsibility. The states of Washington, New Jersey and California require courses that provide instruction and insight into cultural competency to be either a part of standard medical education curriculums for 18 professionals in training, or continuing education curriculums for practicing physicians (Perkins, 2006). These programs are founded upon the recognition that the medical field, by its very nature of dedication to provide meaningful service all people, must adapt to the changing makeup of the U.S population attributed to the largest period of immigration in U.S history. As the disparities in health access and status relating to ethnic and racial groups grows ever wider with the continued influx of immigrants to the U.S, changes in medicine must be enacted on both an institutional and educational level. By working to educate healthcare professionals in cultural attitudes, understanding and, in some cases, by helping them to acquire new communication skills, the quality of care of these individuals is expected to rise. Adopting an accommodating and compassionate attitude towards diverse cultures is the first step in most cultural competency medical training programs. Understanding culturally relevant perspectives on health and medicine are likewise a significant and impactful aspect of cultural training. Clinical encounters are the most direct and frequent interactions healthcare professionals have with patients, and these encounters include of two main forms of examinations: verbal and physical. There are a variety of cultural and individual issues that may alter the dynamics of the physical portion of the examination, but just as important are the effects of verbal and nonverbal communications between provider and patient. A guiding principle within these programs is that when the language abilities of the patient may hinder the conveyance of provider information or inquiry it becomes the duty of the physician to take the necessary steps to eliminate, or at least reduce, the communication barriers. Training may involve teaching providers about how to efficiently and accurately assess a patient’s language competency, and then to choose and employ an appropriate form of interpretation service for the patient. Guidelines provided by the California Endowment 19 additionally stress the importance, should a provider deem themselves linguistically capable of interpreting for non-English speaking patient’s themselves, that they are able to realistically assess their own proficiency in the language, and their ability to effectively discuss subject matter relating to the situation. Likewise physicians should learn effective methods of working with a variety of interpreters and interpretation services (Gilbert, n.d). Directly training monolingual providers in another language may be a lofty and extensive goal, but all providers can and should be taught how to access translation and interpretation resources. As technology continues to progress, many of these services are becoming available through computer and web-based programs (Gilbert, n.d). Professionals should be made aware of the legal obligations and procedures their respective health care institutions are required to abide by, and take action to encourage the implementation the necessary language services. By coming to understand and appreciate the importance of cultural competence, specifically in regards to language, it is the implied hope that educational initiatives such as these will both equipped providers with personal skills and methods for overcoming language barriers, but also that health care professionals will be motivated to support, develop and draw attention to the specific needs for services for LEP patients. Language-concordance, although it is often considered a much more intensive approach, may also be addressed through educational and training means. Language-concordance refers to instances in which patients and providers can effectively communicate in the same language. In 2009, Eamranond et al, conducted a study to determine the effect of language-concordance and healthy living counseling by comparing records of diet and exercise counseling among languageconcordant primary care providers working with Spanish-speaking patients and recorded instances of diet and exercise counseling from primary care providers, that do not speak Spanish, 20 working with LEP Spanish-speaking patients. They found that language-concordant physicians working with Spanish-speakers are more likely to document diet and exercise counseling during clinical visits, than non-concordant providers. This same effect has also been seen for Chinese and Vietnamese-speaking patients. Eamranond acknowledges that if the number of bilingual providers was more fit to size of monolingual and LEP patients it would be the most costeffective manner in which the health care system could address the needs of these populations. One exemplary case of medical education programs taking action to address language services in the Hablamos Juntos Program, which is an educational and clinical branch of the UCSF School of Medicine. The group specifically works to address the language and healthcare needs of the Latino population as they make up the largest ethnic group in the U.S, and approximately 38% are considered to be LEP (Tomás, n.d). The program focuses on developing new and innovative models to reduce language barriers by means of: increasing the quality and availability of interpreter services by developing programs to train and assess proficiency of interpreters, issues guidelines for developing effective translated materials, and working to make navigating health-care facilities a less intimidating process for Spanish-speaking patients. Data on interpreters, provider communication and satisfaction was collected from approximately 2,000 patients from eight different sites, sponsored by the Hablamos Juntos Program, and the Robert Wood Johnson Foundation, ranging from Rhode Island to California. The most significant reported finding from the study found that patients who needed an interpreter and were always supplied with one, reported a 10% higher overall satisfaction with care when compared to patients who always needed an interpreter, but did not always get one (Moreno, 2010, p. 1286). 21 Dr. Chen (2007) makes the suggestion that as more states and institutions consider adopting similar physician oriented programs that they consider utilizing a model that fuses cultural and linguistic competency with various clinical topics, in order to increase the effectiveness of such a program. Considerations for Healthcare Organizations It is of utmost importance for health care institutions and governing bodies to consider not only the types of language services available to LEP patients, but also the quality and effectiveness of these services. Ultimately, neither the universality nor the depth of language policy will be relevant to improving LEP patient care if the final application of these laws is carried out by translators and interpreters who are incompetent or unprofessional. Presently, there is not a national mandate that requires individuals to become certificated or verified by an interpretation standards organization in order to work as a medical interpreter. The recognition that being bilingual is necessary but not sufficient to serve as a medical interpreter has, thus far, only prompted the states of Washington, Iowa, Oregon and Indiana to enact laws which require that medical interpreters meet certain standards in order to work in that field (Perkins, 2006). Oregon, for example requires applicants to provide proofs of 40-60 hours of formal language training and pass a pre-approved certification exam or skills assessment (Standards, 2013). A 2012 study which closely analyzed errors made within a group of professional interpreters, it was determined that interpreters with less than 100 hours of formal training had a median error count of 33, whereas those with more than 100 hours had a median error count of 12. Interestingly, hours of formal training was shown to contribute more to a decreased error count among professional interpreters than years of interpretation experience (Flores, 22 2012). Ultimately the study concluded that upwards of 100 hours of formal interpreter training is necessary to significantly minimize the risk of errors during medical interpretation, which may have clinically significant consequences. Although federal reimbursement for language services is offered through Medicaid and SHIP program, individual states are free to choose whether or not to offer the option to their respective populations (Youdelman, 2009). In their most recent report on reimbursement practices for language serviced, released in 2009, the National Health Law program reported that 13 states, plus the District of Columbia are providing reimbursement for language services for those enrolled in either the Medicaid or SCHI programs. These include Hawaii, Iowa, Idaho, Kansas, Maine, Minnesota, Montana, New Hampshire, Utah, Vermont, Virginia, Washington, and Wyoming (Youdelman, 2009, p.2). Dr. Chen (2007) draws attention to the fact that many of these states have relatively small LEP populations. Maine’s LEP population is 1.7 % and Wyoming’s is just above 2% and Hawaii’s is 12.7%; relatively small values when compared to states such as Texas, New York and California whose LEP populations comprise 13%, 14% and 19% of the state population, respectively (US Census, 2012). The use of unprofessional ad hoc interpreters is associated with increased instances of miscommunication and errors, when compared to formally trained interpreters, and these disparities can have serious health related consequences (Grubbs, 2006). The sentiment that ‘it’s really the thought that counts’ does not hold true in regards to interpreting in health care settings. Flores et al. compared the number of errors made by professional interpreters, ad hoc interpreters and no interpreter during medical interpretation in an Emergency Department (2012). The study found that overall 18% of total errors made had potential adverse clinical consequences. Surprisingly the percentage of significant errors made by an ad hoc interpreter 23 was within 1% of those made when no interpreter was used. That number was nearly reduced by half (12%) when a professional interpreter was used. Ad hoc interpreters are frequently friends or family members of the patient. There are a multitude of dangers involved in this practice. For one, family members and friends are often unfamiliar with medical terminology, potentially both in English and their native language. The interpreting party will often re-interpret, to the best of their abilities, what is being said by the provider and relay their interpretation to the patients. Likewise, interpreters may simply omit items they don’t understand, or feel is inappropriate for them to discuss. This information may come from the patients, and be pertinent to the providers understanding of their issues or concerns, or it may be directly related to a provider’s diagnosis, instructions or treatment plan. Patients may be also be reserved in relaying important information to providers, due to the personal nature of their relationship to the interpreter, particularly when sensitive matters are discussed. The maintenance of confidentiality is additionally a significant a matter of concern in these cases. Interpreters may not be cognizant of the importance of patient privacy, and the significant measures health care organizations take to secure patient information (Gilbert, 2005). Children as interpreters are also a matter of particular concern in these cases. As is true for an adult family member or friend interpreting for the patient, children are likely to omit and edit information they do not fully understand or know how to discuss, perhaps at an even higher frequency that adults. Children may also suffer uniquely in these situations, because of their increased susceptibility to feeling guilt, and a huge responsibility for the information being presented to his or her guardian. This can have damaging effects on a child’s mental and even physical health, particularly in cases in which the family may be experiencing health related suffering or loss. 24 One often overlooked aspect related to language services within families entails cases in which healthcare providers are treating children who, although they themselves may speak proficient English, have LEP parents. In non-critical clinical instances, the child will likely serve as both the patient and the interpreter, on behalf of his/her parents. However, it is easy to perceive a situation that may arise in which the child is unable to speak to providers on their own, or their parents, behalf. Parents are expected to be the primary advocates for their children, and although a parent, in an occasion such as this, may be doing everything in their power to help their child, the health outcome of their child is likely highly dependent on the availability of an interpreter. Studies have found evidence demonstrating that parental LEP directly influences children’s health. In a systematic review conducted by Stanford University, found that there were significant health care disparities for children with special health care needs, which directly correlated to parental LEP (Eneriz-Wiemer, 2014). Ngui et al. (2005) found in a multivariable study that controlling for language barriers most significantly reduced Hispanic/white disparities regarding parental satisfaction with care and services among children with special health care needs. The 2004 DHHS guidelines to Title VI and LEP persons explicitly addresses this topic in the section which discusses the types of groups that should be taken into consideration by a healthcare institutions in determining the number of LEP persons in the eligible service population. “When considering the number or proportion of LEP individuals in a service area, recipients should consider whether the minor children their programs serve have LEP parent(s) or guardian(s) with whom the recipient may need to interact” (Guidance, 2004, p.8). 25 Evidence based cases provide conclusive reasoning as to why children of LEP parents need to be taken into consideration when developing and managing language services. Likewise, if organizations are acting in accordance with these guidelines, they should be able to provide language services and eliminate, or at least minimize, the utilization of children interpreters. These measures would help to both improve healthcare outcomes for LEP patients and children with LEP parents, and mitigate unforeseen effects interpreting may have on a child’s physical or mental well-being. 4.2 LANGUAGE AND EFFECTS ON PATIENT CARE A multitude of public health studies have shown that when not addressed, language barriers in healthcare settings adversely affect LEP patient populations in a number of ways. Communications regarding preventative measures, treatment instructions, and overall patient comprehension and satisfaction with the care they are receiving have all been shown to be deleteriously affected when language services are not provided to patients with limited English proficiency. Preventative measures such as cardiovascular and cancer screenings have been shown to be particularly subpar for LEP populations. Turning a particular focus to LEP Latino populations in the U.S, preventative care such as pap smears, mammograms, cholesterol screenings are more infrequently performed, and are associated with unfortunate statistics including the fact that Latina women are 125% more likely to die prematurely from cervical cancer, and that Latinos overall are more likely to receive an initial diagnosis of colorectal cancer when the disease has progressed to the end-stage (Eamranond, 2011). 26 Patient satisfaction has been shown to be an important baseline measure, which can provide insight into patient’s general health status, and perceived importance to health care providers (Robert, 2014). If patients feel invalidated, or especially disrespected by providers, patients are less likely to be motivated to adhere to provider advice or seek future care. Individual identity is a complicated topic that permeates fields such as philosophy, art, literature etc., but also has its place in a discussion on patient care. Cultural competency training is one way in which medical institutions address potential areas in which patient identity may be particularly vulnerable. Language has frequently been shown to be among the more significant factors contributing to this identity class (Schmidt, 2000). An “attack on...language is experienced as an attack on [one’s] very being” (Schmidt, 2000, p. 49). In health care, the primary objective is to provide a specialized form of public service. As such, ‘attacks’ on individual or group identities tend to be subtle in nature, and tend to be more a matter of discounting or inadequately addressing fundamental components that constitute identity. “Identity may be threatened if individuals’ feelings of continuity over time, distinctiveness from others, self-esteem and selfefficacy are threatened by changes in the social context” (Jaspal, 2009, p. 17). For individuals in the U.S with LEP, a substantial change in social context may include a simple visit to a hospital or clinic. When cultural competency training and practice insufficiently addresses, or acknowledges patients’ language-related needs, it may have adverse effects on patients’ selfperceived relevance in healthcare settings. Feelings of insignificance can be demotivating forces in regards to patient’s personal involvement in their own health care, which can thereby negatively impact overall health (Robert, 2014). If improvements can be made to preserve patient sentiment regarding identity 27 and worth in a healthcare setting by means of offering quality language services, patient involvement in their own and community health care efforts could be expected to increase, potentially along with overall health care outcomes. 5.0 UTAH STUDY RELATING LANGUAGE SERVICES AND PATIENT SATISFACTION In 2014, a study was conducted at the a free public clinic, in Salt Lake City, Utah, which explored the relationship between patient language proficiency, language assistance services and overall patient satisfaction among Spanish-speaking patients. The study was founded on data that indicated that patient satisfaction increased when interpreter services were available to patients. The clinic is funded through non-governmental grants and donations. Patients of the clinic are all uninsured individuals, who do not have access to government-funded health insurance such as Medicare or Medicaid. Patients of the clinic are required to provide proof of income, which places them below the 150th percentile poverty line, in order to receive care. Legal citizenship or residency information is not required for care, as such a significant portion of the clinic’s patients are undocumented immigrants. The clinic reports that approximately 50% of their overall patient identify as Hispanic. In Utah, Hispanics are three times more likely to be uninsured, when compared to the overall Utah population and 20 percent of Utah Hispanics are living below the poverty line (Utah, 2009). Among Utah’s 2.7 million person Hispanic population, approximately 99,490 Spanish speakers report speaking English at a LEP level, or less than “very well”. This constitutes roughly 4% of the total Utah population (U.S Census 2008-2012). 28 For the study patient satisfaction was measured by means of a patient satisfaction questionnaire, the Patient-Doctor Depth-of-Relationship Scale, and questions that were developed by and of particular interest to the clinic staff. Questions used to assess interpreter services and language barriers were taken from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey. Patients were also asked to rate their most recent interpretation services and self-assessed English proficiency. All measures were selfreported by patients and then interpreted by means of various statistical analyses (Kamimura, 2014). Sixty percent of patients that participated in the study were Hispanic. From the total of 170 Spanish-speaking participants, only 10% assessed their own English ability as proficient. Seventy five percent of Spanish-speaking patients reported having used the interpreter services available to them at the clinic (Kamimura, 2014). These services are provided free of charge to any patient who requests them. Interpreters are recruited, and work on a purely volunteer basis. The clinic works to ensure that one to two Spanish interpreters are available in-clinic during all clinical hours. Patient’s rated overall interpreter quality as high. This data is somewhat confounded by the fact that 33% of participants reported having used a family member or friend interpret for them (Kamimura, 2014). This concern addressing the accuracy of this form of translation has not been examined in this specific setting, although studies have shown that unprofessional interpreters make more interpretation errors, than professionally trained interpreters on average (Flores, 2012). Likewise, the accuracy of interpretation provided by volunteer interpreters should also be assessed in the future, due to the fact that interpreters are not required to be officially certified. 29 General satisfaction among Spanish-speaking patients was high, and both general satisfaction and satisfaction with communication was not significantly different between English and Spanish speakers, p-value < 0.01. However, both intrapersonal manner and Patient-Doctor Depth measures did show a statistically significant difference between English and Spanish speaking participants (Kamimura, 2014). This report appears to speak to the need for there to be increased training and education for physicians and other healthcare staff in regards to working with interpreters in treating patients who employ their services. It likewise demonstrates the significant impact language service availability can have on patient satisfaction, considering that overall satisfaction between English speaking patients and Spanish-speaking patients did not show any significant disparities. Increased patient satisfaction is associated with increased patient involvement in their own health care, and thereby, better health quality overall. 6.0 LANGUAGE POLICY AND THE AFFORDABLE CARE ACT In 2010, the Affordable Care Act (ACA) was signed into law by President Obama (About the Law, 2014). Along with many other features, the ACA extends the wording of the Title VI nondiscriminatory policy to include any entity or organization included in the ACA Exchange, or Health Insurance Market, which is designed to help people acquire health insurance that best fits their individual means. The extension of Title IV, within the ACA, explicitly protects individuals from discrimination on the grounds of national origin and language, and holds all Exchanges to the same regulation standards outlined within Title VI. However, the list of specific Exchanges are developed and maintained by the state, and as such may not be universally applicable to all LEP individuals in the U.S, depending on their state of residence. 30 Coverage and opportunities afforded through the ACA only extend to individuals with lawful immigration presence. However, opportunities are extended through family plans to families of ‘mixed status’, meaning that some members are legally residing in the U.S while others do not have lawful status. Immigration statuses of family members who are not the immediate enrolling party do not have to provide immigration status information by coverage organizations. Documentation and communications between enrollees and insurance providers must be linguistically appropriate. In some cases, such as notices, must be translated into the appropriate language. In other cases the provision only requires that information be in “plain” or “culturally and linguistically appropriate language”, which does not expressly require translation of the information (Youdelman, 2011). While the development of program to standardize and fund patient navigator services is mentioned, which would help direct patients through the various healthcare complexities and procedures, no language service specific language is included in the document, which means that LEP populations may not fully benefit from such services. Perhaps one of the more exciting and progressive provisions of the ACA in regard to cultural and linguistic competency included programs to educate and reward health care professionals for increasing their knowledge and skills regarding the treatment of diverse populations (Youdelman, 2011). In order for these programs to have meaningful and potent effects, it must include language that will require or at least incentivize healthcare workers to be specifically trained and educated in utilizing language services, and working with professionally trained interpreters. One item of concern I personally encountered in reading through online resources (healthcare.gov and obamacarefacts.com) providing information about the ACA, was that there 31 was no resource available that specifically discussed or informed patients about the antidiscrimination provision included in the ACA, or patient’s rights to language services and resources. In analyzing and reading through a number of documents, both in Spanish and English, that specifically elaborated on the rights and protections included in ACA coverage, none of these truly discussed or mentioned the extended mandates regarding individual patient language rights within these policies. This occurrence again brings the discussion back to individual empowerment. In a 2013 poll, 60% of non-white adults reported that they did not personally have access to the information they needed in order to understand the changes included in ACA (Americans). If new mandates are put in place, but those populations that would be most affected by its implementation are unaware or weakly informed, about their existence and implications, than the likelihood that they will be ignored or abused increases substantially. When government agencies pledge to make information regarding the ACA available in plain and widely-accessible, then the rights to language services, which are targeted towards minorities populations, should be just as equally accessible and clear. In nearly every instance, information is power. A bottom-up approach, which focuses on the capacity of the individual to bring about change, is an effective strategy that is widely utilized throughout various health care practices. By empowering and encouraging patients, they become more involved and dedicated to their own health care, and motivates patients to advocate on behalf of their own legal rights. As stated earlier, contemporary progress on this front has mainly been achieved through issuing complaints of non-compliance to the Civil Rights office. Hence, if a majority of LEP individuals were well-educated and informed in regards to their legal rights to access language services, the backing for movements to expand and improve these services would be expected to grow substantially. “Patients who know how to navigate the 32 healthcare system often have different perspectives than those who provide their care, and can offer insights on how to overcome the barriers that patients face to help improve care” (Robert, 2014, p. 1). Patient’s feeling confident in their abilities to understand and be an active participant in their own health care has been shown too substantially. Economically speaking, uninvolved patients have been shown to accrue higher overall costs than patients who are engaged in their own care (Robert, 2014). 7.0 CONCLUSION Societal and political issues regarding language has long been, and will likely forever be, present in U.S society; whether it be related to the presence of a ‘foreign’ non-English language, or a dialectal or non-standard English in the U.S. Language is intimately tied to individual and group identity, as well as national and political power; as such, it is believed that there will always be those willing to fight and stand-up for their language rights. As discussed in the ideology portion of this paper, these seemingly ‘either/or’ mentalities in regards to language usage, particularly in the U.S, significantly impact individual’s rights and gives many cause to fight against those who speak a native language different from their own. As the United States begins to implement and explore new laws and regulations relating to health care, it is the hope that those portions of the laws regarding language services and policies not be overlooked. Despite the fact that since 2000 the legal foundation regarding rights to access language services appear to be mostly well-defined federally, and is even more explicitly laid out in several states, the actual weight of these laws has shown to be insubstantial in most cases. While there are numerous cases of private, state and community-based regulations regarding language service access for LEP patients, the laws regarding language 33 services in healthcare in the U.S are frequently inconsistent, ill-defined and “[a] patchwork… which vary from state to state… language to language, condition to condition, and … institution to institution” (Chen, 2007, p. 363). 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