Bilingual/Multilingual Service Delivery in U.S. Health Care: A Synopsis and Critique of the Recent Literature

31 Pages·1996·1.6 MB·English

Bilingual/Multilingual Service Delivery in
U.S. Health Care:
A
Synopsis and Critique ofthe Recent
Literature
*-i'Cv;Csnter
iin, Cente
.Januarvl996 RHo°ckovS;l,le',fm*^^2'08 ifte650
1-800-444-6472
U.S.DeparrmentofHealthandHumanServices
HealthResourcesandServicesAdministration
BureauofPrimaryHealthCare
OfficeofMinorityandWomen'sHealth
Developedandproducedbv:
KenErickson.SeniorResearchAssociate:
PennyAnderson.ProjectDirector:and.
CathleenGrain.ProjectMonitor.
LTGAssociates.Inc..underContractNumber240-95-00040
. .
Bilingual/MultilingualServiceDelivery
inU.S.HealthCare:
ASynopsisandCritiqueoftheRecentLiterature
TABLEOFCONTENTS
INTRODUCTION
...
KEYTERMSANDCONCEPTS
CLoamngpueatgeEn'cCyulturalMediation.
THEKEYQUESTIONS.
GROUPSREPRESENTEDINTHELITERATURE.,
SERVICESDISCUSSEDINTHELITERATURE
PRACTICALPROBLE.MSADDRESSEDINTHELITERATLHE.
LinguisticDi\-cRsity
S.TAohbemsee.RnS.cOoeLlEuoOtfFiIoCnnutsletruprreete:^ " 109
10
STRENGTHS.\NDWEAKNESSESINTHERESEARCH 12
Theory
Method 12
EmPIRIC.UQL'ESTIONS 1134
RESEARCHA.\DPOLICYIMPLICATIONSANDRECOMMENDATIONS 14
GGGaaapppsssiiinnnPKPlrnaaocnwtnliiecnedgge.andUnderstanding ...111674
WORKSCITED
.19
.\PPENDIX
Bilingual/MultilingualServiceDelivery
in U.S. Health Care:
A
Synopsis and Critique oftheRecentLiterature
Introduction
noniebisltiantigsutailcaslertvabilceesdaenlidveAreyormetiUc.aSl.dhiesaclutshsicoanrsefsoeuenmdfianrsreommoevoefdtfhreormestehaercieixpleirtieernacmerse
ooffipsastuieenstcsoamnmdocnlilnyicfiaancse.dnOynlfyamailfieeswarenadl-hleifaeltnharcraarteivpersofaersesinoeneadlesdaltiokei.llustratethekinds
During an ultrasound examinanon. a seven-year-old giii is used as a
translator for her Spamsh-speaking mother. The Endish speakins
radiologistasksthegirltotellhermotherthatthebaby,herlittlebrother-
to-be.wiilbestillborniHaffher1992).
ASpanish-speakingbeefpacidngworkerwiihcumulativetraumadisorder
in his shoulder and some English abilit}' drives five hours to see a
specialist. TheEnglishspeakingdoctoraskshowheisfeelina. Theman
repliespoiiieiyiha:aeis "justfme. feelingverywell,thank'you." The
workerlatersayshewasjustbeingpolitebutthedoctornotesthattheman
isnolongerinpain,returnshimtoworkwithoutfurtherinquiry,anddie
man'sconditionworsens(Erickson1994b).
AViemamesehealthcareparaprofessional. makmgatranslation foran
AlDS/fflVbooklet,renderstheEnghshphrase"thedoctormaynotbeable
totellrightawayifyouhavethevirus" intoViemameseas "thedoctor
maynottellyouniiiyifyouhavethevirus." Thetranslatorexplainedthat
hisexperie.nceinViemamhadledhimtobelievethatmostdoctoiswiil
hidethetrathfrompatientsifthenewsisverybad.""
Sometimes,somethingis"missinginthetranslation"inhealthcaresettings. Toooften
thetranslationismissingaiiogether. Thissynopsisandcntiqueoftheliteramrepertinem
tobi/multilingualhealthser^•icedelivery-vvillprovideabaselineofinformationaboutthe
stateoftheaninbilingualandmuhilingualservices. Itwillalsopinpointstrengthsand
weaknessesinthecurrentresearchandofferrecommendationsandstrategiesforfiiture
effons. Thesynopsis begins with adiscussion ofsome keyconcepts followedbya
'Tnisincicer.:hasreenrepcrrea:nseveralsociaiser.-icetrainingevents:itrookpiacewhile
t1h9e89-p)r.imar.-authorwasasoc:aiser\-ices administratorin GardenCit\- Kansas ^Erickson
tppdhrriaeescscteuinsctsareiledoc,inemnooptrrlgaifacmonacuitirizeoeqsnduseubsnfytdoiretorhnleisriseretvthhiqaeeutrwe.uhstsaiveoemnlsg,urieasdneedadrnctohh.teinr.ge\sntehaAeroctphheernoerdveitixiecwad.li,si-T^mTleiade-visloikdteoeriv-aotfaueiracetauiirsetsahneodnf
KeyTermsandConcepts
hAlLoiagwnnagegruvuiea(sgr1te,9s9bhi4sea)cviaaenunsac:eaccTioitanismpsiiodnseesenriebad(lbee1ld.9e9ta0on)Srdoehmsvaoeivmeeweldtihneigommuoweinsstlsiaticnmrpgateutenaeregdmteirtinhasaobtllaoedcgdljyreaaerrsia^ssojenabd.rnaieaonnfl-lttfvhhreoeui'lgenihttvreivorinadntmuaricuenei.-sdtashbeloriukete
Langnaqe/CultnirnIMedintinn
sAlaunmgmucaaorgreie/zceuacitoiunnrca'e_.pi:tsmseedicintaitoinuonnod.fetrhsetWashnyadntionpgshiass.bib/emeuintillienaarunaeid ahbeoaultththissercvoicneceptdeliisvebnr'ieflivs
avuabIlsoinnseueyorntwoudhiniaionsrercybi'mrleu.eavcavnaoeigusleTusvwahtee,hgieecs-,asei:onelc-raiasanmacgn.lhi^geaecuaawnoglahntetgi.tmh'eecccxchuitalslriitiemstunerutrmwacralhotahiurnrmscemeeahocdgotriceinaeonotmenltimrahotaunahnlngan^ititoscsihaoagnaudtevnneiodfola"sivnnt,nerdeosawdncolcscrairaudnasorstgss,iusaoi(annanAg"ngueadscoatturgiislrvnea"ianbt1mrvgt9meeu6ajrua2er^)ngc.r.detesetorLaratataicnnkuog'aeinurnnai"rrg"obaiewvis
Coinmunicationamongmembersofdifferemethmcgroups ofteninvolvesanunequal
(exLcahoaonvge1,96r4e;flZeecnt—egilaac1o9n8s7c;ioGuaslu1n9d8e8r)s.tanItdionigieonfrhesitsstoonncaldlivffeurneenatuaaisssuomcnitalio'n•se^'abtoiounts
gooQwiiI(orlacK-jiereof)onthepanoftheinteractors(Smith 199- Sin-^h L-le and
Matohardjono 1^38; and compare Erickson 1994a:95). In contemnorar^- iheories of
linguistic competence, such assumptions are considered essential for communication
rs(eeBspaeacarrahctmheaerlnsan1mg9ua9am0g;et.aHm;ytsmtiehamstmeld1a9in8ag8tu;eagcGeorniatcneexdt,1c9ua7ln5m)dr.edieaMr\elviadnteahrilsvciuislcutaguigrleevsftisrnosmethpaaotrnaeibtlaenios{th\deiorfaf.iicuS1l9ot9m4te-o
KleifgenandSaviiie-Troike1992\ AccordingtoHaf&ier11992:259).
Health care professionals must recognize that the situation is always
bicuiniralandnotmerelybilingual[Haf&ier1992:259]
Tocomplicatema-ers.languageandculture,usedastermstodefineaoarticuiarethnicor
Imguistic group, are sometimes highly problematic e^/en within national boundaries
Mexican(Duran:^81)andNewYorkPuenoRican(Zenteila1987)vanetiesofSpamsh
areexamples. Ge.-.aercanalsobeafactorincommunicaiion.presentingaboundar:,-not
•omiKematpreseniedbydifferentnauonallang^aages(Tannen 1990). Further,because
culniresarealwa:--;changing,languagesarealwayschangingaswell,Hasseimo IQ74-
(2]
Williamson 1991). The iiterature reviewed here demonstrates how providing
bi/multilmginlservicesinvolvesmuchmorethantranslationandinterpretation. Health
careresearchersmakeuseofmanyof±etheoreticalpointssooftenmadebvlinguists
sociolmguists.psychologists,anthropologists,andcommumcationresearchers.' Theterm
language/culmral mediauon reflects :he widespread understanding that more than
translationorinterpretationareatissueinprovidingbiy'multilinguaihealthservices.
Competency
uLsaendgubaygeparitsincuoltarapuesoefpilielicnonpcaerptitcublyaritssietluf.atiFonosritshewhpautrpmoastteesrsa.thLainndg,uilsatnsguusaegethaestietrims
wcmootrmodpseaTcocCroTugtnhytetosmoduenisndctsre,irbpseetrrteshsosen,aalpcaucuiostemysm,oufnaisncpdeaatsiiecoeqnrus.entocTethatekhseaetbometalhekmeceonnttthseexmtinaicnnltudodelsaenmngtouernaecgeest.hfaenaTnijhrueesyst
alelvseolioncflpurdaegpmraatgimcatciocmpskeitlelsn,csekiwllisthaobuotutawhhiagthtolesvealywofhecnu.ituSnpileabkaecrksscraonunnodthknaovweleadhsi"aeii
This knowledge not only :.-ciudes :he immediate simation andIts meaninas. but
situationaily specific conventions for :um-raKing, pause and response time, register
^formalorinformalspeech).2rAvocabuiar>-. Language/culturalmediationmustinvolve
alltheselanguageelementsandfunctions(Bachman1990:87). Pauweis(1992)provides
ausefulgraphicsummaryfor"iiepurposesathandfFiaure1).
-Assumcticnsacouttheencounter
(e.g.iceasaerivedfromhistory,tradition)
SOCIO-CULTURAL -Expectationsaooutthepurposeofencounter
"Attituaestowarastheotherparty
.Disccurse:wnaiconsiitutesan"intakeinterview."
an"examination.'or"treatment""
interacronaltools:non-verbalcommunication,
LINGUISTIC tum-taKingconventions
"SpeecnActs."ntualbitsofspeechthatdothingslike
settherelationships:regular(fonnalorinformal).
Sounas/accents(the"phonological"leveloflanguage)
\ IMinltonation/Rhythm/Stress(the"prosodic"elements)
\W('ords/meanings(the"iaxical-semantic"component)
Grammer(howwordsandmeaningsarean-anged)
Figure1:
Elementsoflanguageinmultilingualhealthcareinteractionshowingthecomplex
relationshipofpartsoflanguageandculture,adaptedfromPauweis(1990:208).
Cmmraiand"linguistic''eiemsntsare:iri:edii:hreepointsinPauweis" model. Other
researcherswouldremmdPauweisthattheianguage/culturedistinctionisaproductof
academichistor--.and±etwo ore linkecinmanyways iBourdieu i9Q3; .\aar 199^).
[3]
rNeesveearrtchnelreesvsi,edwiechanprovidesausemireferencepointandavaluabletaxonomv• f^ort"h"i^s
prrummophdPneuntatreisavdboaiesiimeihDlrngcervtinmsaoswlethemcvnn.i.imiene-ecasrgoedaatCtrnarnwichas.amecdheornm.anetphcastaresyo^FIuopavsenumcavliul(sltnttietmelwihdheempoeeaebaonetrrcdentfnidas,ssntorsttmosentgahrirasheekacoesnenetrfy.dydehsnuirseliramfarttmatteelooepnhdltcamplgeiyhunaeulyaisitltandmeinujhgiedsaedgaenttdoinsr,rtodn',gaasnntiopaoegtennpbltthrworoeweetansinaxrhnmegtrecagumewercutaiawdldeowltticrgeeiuthton,daltorhgineahnazhctlmdeieeonateaztdufpnhlewmshehtetsoeoaamshmonmrtcntohorkoctyhelefocaneosrwdlogtmesfimafhiotortrnecprfsohteaarutmhbulotlcieiahftmtFl.eedarriaieisaeovngnlpfslvueuedafiiaburlmteorlaleifrenheeieeeanibnnaIlatsamett)csmtsn.t/eordtehasneihireccnfsneaan-aoicnilArFtutiwuiohtnie<soehoddnittlepnirertrioLasmohenlfnaveiTteinat1ah»ddthtniciaeshavtssehrseo
TheKeyQuesrions
mbodpTtaerhlosivAiresipveaeespwrlseo,i/inntohasenetiriaahnaixiecmteranec.n.u:.aar9rrr9eeet0Tvnn.eitam2ceshaiwmd(iAcdtrasererlesuvasumimsiermmeiewdamt.,enairazsrmape/meoprstrecehgahoar2oadn2nnoitlozsteoehhmsdgeosayawb,ntyiyeosanprnigfcdaomencoloadusafcstnhrmsbeiatugrso/atemsoiautcenrihlecte-'tihoshlpueirarnoduesrvitnueihaossosln)erisasoc(hrnosecv)aahoe.lDfrdnQf:eueeideaancusdr-ait'ismrtinecoaogbrnsslsoieevnpritovahdiitanencthdd,tee
alnansgwueargse-tahcecteosislioDwiiensge.rk^enyceqsueisntihoenasl:thcare. Theliteratureisreviewedtoseehowwellit
•• WWhhaattsiieartviiocneasialraengm^ejdagieatgerdo?upsandsub-groupsarerepresentedinthe:iteramre'^
• Whatpncticaiproblemsaredealtwithintheliterature?
. Whataresomeofthetheoreucal.methodological,andemniricals^ensthsand
weaknessesintherecentresearch?
psTluhagengneedsrisns.ocnusssitoonrmoafkistnrgentghtehsreasnedarcwheamkonreseseusseftiinltfhoerlpiotieirca'vturmeakweirllsbaendfohlelalotwhedcabrve
oIi-LtnnTacdhnKleegauxuncateasoagnaieaslsooBoLwtceihiihbeonarrig.vai.innrgoeeursSsiuseAbHtabjiorseccitcsndr:rmathcgdoetsioa.lsdsclUioinnunwigrcevsireseureedsaiairnuntcgsayheiemdyose:sfdivKsiaacDnaniielnssdassesmacrechtAdcoaciootcailradodlnehionmigAsidbeci:srnot.sirmtsnash)fcse.ot:srrP.mertasarteEcaianRrorsiIncccChuiI.innttsoduLoreAiaxa.:.n---dIsmuieneraia'dov-oieeorcTisihaoinenote^;dv
tnxnscuimrainursing:mterpre'.at:on.andtranslationmmedicine:biiinsuaiismorimmioraiion
inneaitncareanainhealthcareaccess.
GroupsRepresentedIntheLiterature
rAesileTcatbslteheInsehwowism,mitghreatriaonngebuotfdloaensgunaogte/ccouvleturratlhevtaurlilatriaonngecoovfenreedwbivmmiregcreannttsstudTihees
adpepfairmeunotnahelrep.rooiemsassociatedwithseparatingoneianeuas~eordialectfrom^anotherare
piEnuvdbeilnviicdsusmacalhlsololusstsamt(egKsretliihckekeeUKr.aS1n.9s9a5hs)e.aslth.hoAswcpamrooeprulesaytsdiitoaennms6sc5hainflt,aennvgeouracgoheuosnptsepootfkoelanbne'sbuvcaossmempsdleesntpteoskeinnThbitevs
eltafnagmucagaensdrcuelptruersaelntdeivderisnityt'h,eaUp.aSt.telrintserpaamwrneerdefblyectthoenmloysttherecmeonsttwoabvveiooufsunpmatitgerrantsioonf
(Lamphere1992).
TableI: Langu.ageRepresentedinU.S.StudiesofBilingual
HealthCareDelivery-'
LanguageGroups
orSub-Groups NumberofStudies
NamedinRecentStudies
Spanish(notst:ecific; 8
Mexican.Amencan 5
Mexican
:
PuenoRican
i 1
Pormguese
i {
rimong 3
Vietnamese
Lao i 1
Khmer
j 2
".Asian*' j 1
(Kraut'shistoncalessay[1990]isanimportantcounterpoim.) Manvhealthclinicstaff
will not find the language or cuimrai groups they serve represented in the recent
literature. Tonameonlyafew.Koreans.Sikhs,Russians,andEuropeanimmiarantsIre
notdiscussed.
Withinmuchortherecentliteramre.diereisahimthatmorecomplexdistmctionswithin
languagegroupsexistandthatthesedistinctionscanmaneragreatdealtoclinicians.
Haffaer(19921providesspecificexamplesofdialectvariationswithin.MexicanSpanish
thatmakeasignificantdifferenceinciinicaicare. Brooks(1992)makesuvoparticdariv
^Thetotaldoesnotecuaithenumoerofstudiesreviewedassomestudiesaretoogeneralto
beenteredintothetablewhileothersaiscussmorethanonelanguagegrouporsub-group.
[5]
sddbioopamccospttkeooodernrsnsa'onnaaEtrmnespogooncnniiogsnattnlshncopamlsrtapoisitvtstiheacilsoisreprnseeoctagcaykafc,erfurdapm:slaatttoihyhfooenuEm,ignamghmlkpsioeesrtvhthae.airsndacHlicefiaofssofeefri,tsehwn"ethcdheaoaetcn(tioolBcnrirli'neovessoukaitnsnsaotiltskce1"lc)9eat9lha2tlao;ntd"asvHdoaatdcfnhrifeeoeitiisifeesaecrcsttt"h1ote9f(h9aaiE9tsnd-siesuaiReoliaemsocyehft
1993;Rehbein1994;Sianiz.Dee.andIngram1991;Pauwels1994). ' '
tEah.nexgrceueaptwgeaf.sorl(HiTtathlfeemrdeeirasrc(eu1sm9s9iao2nn1yoBefrxoatohmKepsl.seos(ci1ai9ln92tc)hleaasIsnmdgourIinsrgterigcaismonla(ilStaeirdnaittfsuf.reer:Deenfeco.resSapnwaidtnhiIisnihigrsaaemenaD1ti9uo9rn4aa)nl
[1988]orZenteila[1989];andLuong[1992]forVietnamese.)
Somesmdiesofferconclusionsbasedontheassumptionthatthereisasociallvbounded
rghe"e.ragsxodreauomaluppreplcso'ehsr.rssgeeurpvmForelmuerapasessrekn.pwet'sreeyudrdcdeohbeoysalsenosrdgn^oi'omcet.dae^liubvtymedsribtu/atmgegn1ec1o±nl9seis9enr3sia)rcl,sewaehtfdtehoehrenrnyiecotsxfhmiaeddtmyeihpneeltvdieinf.s,iaiettrTdue.dorheeU"nv.osoAftfsmiotaaiuhndnet"edhnsetctilihmtifainevtiircamw"sn.hAt"siiAiecTsashlinia"eb"nierA"ctlswibiirseeainenaet^n"ns"
cVclliiineeinmct?as)m.eansaecviiismictimagnsaeK-o.-reenatnhoculignnicthtihsessiammilearaistvaisHmthoenatonriecruo~sfeethveiisritriens"aeaarcPhun(jiasbia
Thisproblemcloudstheresultsofother%visesophisticatedsurvevresearch Kirkman-Liff
aavnodidMtoenlderpanognoenosia(s1)9u9s1e)sttheelecpahtoegnoer>s'u"rHviesypa(nsiucp"palnedmetnhteendcobvm'namr-eosertshoenheianlttehrsviteawmssotof
those inten-'iewed in Spanish uiih those inter\'iewed in Enslish. The language of
interviewisfoundtobenon-sigmicontforadultsbutsiamficantfornredictincrthehealth
stamsorchildrenintheimer^-iewsuoiect'shousehold. Theiressavoilersnoexnlanation
dfoermtohgeirrapnnmdcmgasn.a Tadhmeimrsesteraartcihoenrsvra.roipaeblfeosrbteonearsssetsastistthiecalEtneaclhinsiha-uSesoatmoschondtirfoflerfeonrctehse
Suchanalyticprocedureswillnotcorrectfortheabsenceofatheor^'thatsuasestshow
languagevariationcomesabout.
Kirkman-LiffandMondragonmighthaveexploredlengthofresidence,economicstams.
andcountryoforigin,amongother-Jiings.duringtheirinterviews. Hadthevdoneso*
theymighthavereachedmoreusefjlconclusionsaboutthemiluenceoflanauaaeuse'
Nonetheless, their general fmding is important: "Public health research ofHispanic
sppoepcuilnactiit}o'nswictahntbheismhoerteeroignesnmeuonuesntaglroutpo"wa(r1d99p1o:l1i3c9y9)i.mprOonveemesnmtdvifinittihnecrleiatseersatuirtes
reviewedhereassessesclientsatisfacnonandavailabilityofa"doctorwho speaksmy
language" \vithoutaddressmgthevarietiesoflanguages ser\'edatall (Tn'ACHO 199'')
OthersmdiesgroupHispanics(StejnandFox 1990:Ruiz.Marks,andRichardson1992)
under one analytic umbrella. .rls is a ±equently encountered weakness in the
hypothesis-testinganddescriptiveresearchthatrelateslanguagetohealthcareaccessand
outcomes.
[6]
ServicesDiscussedintheLiterature
sMhaonwynsimndTiaebslereI-I.zibeewleodw.forthissynopsisaddressspecifichealthcarearenas Tneseare
TableII: Service.AjienasAddressed
HealthCare.'\reiia NumberofStudies
Studied
Generalortheoreticalstudies 7
Pnmaryhealthcare(general) 4
andwomen
immigrantorminorityciinics ^
anawomen - 1
andAIDS/HIV 1
Mentalhealth 2i j
Healtheducation 2 1
Nutntion/weishtloss
Emergencyroom
Nursmg
1
ATsheirdee^afprpoemarsmattoerbnealanaenmdphcahsilidsohenalwtohm(e'naddarnedsswedombeyn'Issshaecaslt1h99is3s)u.esliitnertahmerelitdeeraatluirneg.
specifically with :.-outh and children :s strikingly absent here. (Kirkman-Liif and
Mondragonnotecriidren'shealthasaspecialissueinepidemioioaicalresearchamong
Hispamcs.)Theiiieraturedoesnotincludeadiscussionofmenandmenshealthissues
s(aolmtehoeuxgthentt)h.ePSninegreerisannioclceovoenra.geAIoDfSg/eHrIiaVtri[c19c9a3r]eianddtrheeslsietserbaomtrheacnhdiltdhreerneasnedemmsetnobteo
littlecoverageofpre-servicetrainingonbi;muitiiingualissuesforhealthprofessionals.
Otherareasofhealthservicedeliveryarealsounderrepresented. Theextentoflanguage
minorityemployme.ntindangerousoccupations(Stull. Broadway, andErickson1994;
Griffith1993)makesitsurprisingthat±qliteramresearchdidnotrevealanmterestin
bilingualcareissuesinindustrialandoccupationalmedicine. Rehabilitationmedicineis
aclosmomunnoitcarteiporensem.-.trend.marySpceacrieilscetthienagls.uhPiiesaslutehscacroeveprroefdessiniontahleswliitthertahmeremoestm'pphaatsiieznet
contactrendtohavepublishedmosiofmearncies. Nursesandprimarycarephvsicians
seem to be especially active in repomnc problems and solutions in'biiinauai health
servicedeiiver>'. Severaloftheaniciesprovideusemisuggestionsforgenel-alclinical
settings(Woioshm1995:Hafmeri992:Issacs1991:Cousins1992;ClabotsandDelnhin
19921.
m
PracticalProblemsAddressedintheLiterature
mTstchuleduydlei:otferammurletilcionvgeuraslahenaulmthbecraroefdperlaicvteircya.l prTohbeletmhsreethaairoabrilseemfarroemasthdeispcruosvsiesdiohneroer
• Thediversityoflanguages(and%vithinlanguages,)foundinclmicaisettinasand
approachestobridgethem:
• Theabsence(orpresence)ofqualifiedinterpretersandtranslators:and.
• Theroleofcultureincomplicatinghiterpretationandtransianon.
LinguisticDiversify
MfoousntdEmngltihseh-UsnpietaeiddnStgatAemseanncdaneslsearwehesruerpinnstehdetwoolreiadr.noaibtoeuntitnhesidniavleersciotymmofumlannessuageAs
clmicdirectorinwesternKansasrecentlyreponedthatshewaswo'rkma.\^thMexican
native peoples who spoke an 'onw-nnen Mayan languase: second-senel-anon German-
speaking Mennomtes from Chihuahua. Mexico: and the clinic^s "usuai" clientele of
lowlandLao.Vietnamese,andMexicanunmigrants(Schwab1995").
-AnyofPauweis'dimensionsoflang^jage(Figure I)canvar/bvsocioeconomicstatus
region,andevengender. Giles.Williams,andCoupiand(1990)demonstratematagecan
ebveeanswihgemnnctahnetyssuupbp-couslemdrlaylsfpaecatkorthiene'sxacmhea"ngleasngbueatgew.eenInnthhvesibciiiamnasuaalndlittheeriarturpeiieonntisv
Brooks(1992)andHaf&er(1992)discussthisatanylength.
CAclesouammmWmmoualmmotslsyahn.1ig9nu90aIs]fgu)ega,gehetsifhtfgesehn,ctdliieatvgnemrlgaeyueya(gofennfo-dtepirvbtoeeorisiipsctoie>sev'sneicmnbyaleyyiesafbnoreersceadisonsscatigrone}rs'nsu.err:aamolnoldulynegtaiaamvcbeclaneelnlttptherhedoebt[lilHmaeeanm'kguuiftatogatreahks1ee9asi9ln2tt;hoa
careproviders.
Hafmer. ontheotherhand, suggeststhatclinical staffcanleambasic conversational
skills ratiier quickly. Most communities seem to have onlv four or five dominant
mlangL'jaamgpehgerroeups19(9e4.g)..PricTehearnedCiosrdetihleor1e9t9i4c;alansdupcpoomrptareforthethceomimduemat^t'hadtescerfifte^cttiiovnes
communicationdependsoneffectiverapponandsharedbackgroundknowledge more
thanitdependsonsharedle.xicalcodes. This, inturn, suggeststhatlearningtomake
politeconversationforrapponbuilding.mayhavepositivechnicaivalue,sometiiingthat
couldbeexploredempiricallyinnimresmdies. Italsosuggestsasolutiontomepro'blem
Woloshinpointsout.namelythatitisunlikelythatdoctors-xulbecomerluentmseveral
languages. Tneymaynotha^•^:obefluenttobeeffective.
[8]