Seattle, United States

Interpreting Diversity in Healthcare

Harborview Medical Centre

February 7, 2011

Removing cultural barriers helps patients and providers achieve better health care.

Harborview Community Relations

Harborview Community Relations

Whether treating diabetes or providing prenatal education,  culturally sensitive materials and mediation can be as important to health care as speaking the patient’s language. At Harborview Medical Center, learning the difference is changing health outcomes for Seattle’s newest residents.

“Cambodians generally don’t think about preventive care,” explains Jennifer Huong, a Cambodian cultural mediator who works within the community. “They tend to just go to the hospital when they are sick,” she explains about her work with newly arrived Cambodian mothers living in the Seattle, Washington State, area.

As part of Harborview Medical Center’s cultural outreach programme, Jennifer discusses topics like thermometer use and when to administer ibuprofen to prevent high fevers in children (and an unnecessary visit to the local emergency room).

Cultural outreach is just one of the programmes that the Harborview Medical Centre has specifically designed to address the changing needs of their patient population.

A Holistic Approach

The service area for Harborview Medical Center in Seattle includes the 1.8 million residents of King County, Washington with an increasing number are recent immigrants to the United States. In 2006, over 20% of the population did not speak English at home.

The population shift prompted Harborview to develop interpreter services in over 80 languages and dialects. In 2009 hospital was able to help non-English speakers during 115,000 patient visits. Additionally, the hospital’s Community House Calls programme sends specially-trained bicultural and bilingual caseworker staff out into the community with a range of services including interpretation, cultural mediation, case management, advocacy, follow-up, assistance in finding English as a second language (ESL) classes and citizenship classes, coordination of patient care, health education and home visits. These mediators work within the community in six different languages: Spanish, Somali, Vietnamese, Cambodian, and two languages from Ethiopia, Tigrigna and Amharic.  Patient information on a variety of medical conditions is also available on site in these languages. Community response to the programme is consistently strong, with Community House Calls caseworkers helping more than 850 clients from across the city’s mix of cultural groups annually.

To make information about culture, language, health, illness and community resources directly accessible to health care providers who see patients from different ethnic groups, Community House Calls also developed a web-based database called EthnoMed designed to be used in clinics by care providers in the few minutes before seeing a patient in clinic. For instance, before seeing a Cambodian patient with asthma, a provider might access the website to learn how the concept of asthma is translated and about common cultural and interpretive issues in the Cambodian community that might complicate asthma management.  EthnoMed is an open public resource that can be used by anyone in the community -or across the country.

A Two-way Relationship

Caseworkers like Jennifer who work in target cultural communities also provide feedback to the hospital staff about the norms and traditions of their patients,  which in turn helps improve their treatment options.

According to Marine Pierre-Louis, manager of Community House Calls, it is not about imposing Western culture on those from other countries but about finding the best way to make sure the patients’ needs are met. “The programme sets up a place where the knowledge of both communities [ours and theirs] intersects. Treatment plans are negotiated so that it’s not just accepted, but welcomed, by community members,” says Pierre-Louise, “and that doesn’t happen unless you know the community.”

For instance, cultural views of “personal independence” can impact treatment suggestions. “Allowing a Somali man with a back pain to stay in bed is a sign of respect,” Pierre Louise says. “The relatives are saying ‘Yes, he’s dependent on us, and to push him to move would be saying we are not respectful.'” The challenge and solution for caregivers comes from understanding this and then finding a different motivation for healing that brings the family on side to support the proposed treatment.


As Johnese Spisso, R.N., interim executive director of Harborview Medical Center and vice president of medical affairs for the University of Washington describes it, “We need to work with patients, families, communities and other health care providers and agencies to give vulnerable populations the care they need…. We have to reach out and find ways to influence health behaviours.”

Harborview’s dedication to breaking down these cultural barriers is reflected by the $3.7 million they invest annually in the community health promotion and interpreter programme.

In 2007, the Harborview Hospital was recognized for its dedicated approach to community health care by the Foster. G. McGaw Prize for Excellence in Community Service. The $100,000 prize is sponsored by the American Hospital Foundation, Baxter International Foundation and the Cardinal Health Foundation. The Foster G. McGaw Prize was created in 1986 to recognize hospitals that have “distinguished themselves through efforts to improve the health and well-being of everyone in their communities.”

Making it Work for You:

  • Meaningful outreach programs are built on carefully cultivated relationships
  • The most important factor in developing outreach programs with and for under served communities is building a foundation of mutual respect and trust
  • Successful health promotion means working with patients, extended families, community organizations and other groups to bridge cultural differences and linguistic barriers
  • The target population needs be involved in designing the program
  • Establishing cultural competency means taking time to ensure your institution's own culture is adapting appropriately.