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Language Barriers in Healthcare Information: Communicating with Bilingual Users

The rapid growth of the Latino population within the U.S. has been well documented, but there is scant knowledge of user requirements related to healthcare information. Research conducted by the Pew Hispanic Center in 2007 found that among Latinos who are predominantly English-speakers, 87 percent go online, compared with 76 percent of bilingual Latinos, and 32 percent of those who are predominately Spanish-speakers. The conclusion has been that non-English-speaking Latinos do not access the Internet because of language difficulties.

Research conducted by AOL in 2006 found that the more acculturated Latinos are also more likely to speak English and use the Internet. National Cancer Institute (NCI) research findings from 2006 indicated that less acculturated Latinos with no online access are looking for online tools to help them bridge the cultural divide and navigate the U.S. healthcare system.

To better understand the online health information needs of underserved audiences, such as Latinos and the healthcare professionals who serve them, NCI conducted user research in 2009 on the cancer information website en español ( We conducted usability testing to determine if there were any differences between mainstream U.S. audiences and Latinos.


Using a broad-based approach, we recruited healthcare professionals of diverse Latino ancestries in Los Angeles with different levels of acculturation and Spanish language proficiency. We hired a recruitment firm with onsite bilingual-bicultural staff and extensive experience recruiting Latinos. Recruitment materials were developed in Spanish and English and disseminated to community contacts. Screening was also conducted in both Spanish and English depending on the preference of the potential participant (see Table 1).

Recruitment Criteria
Acculturation Time lived in the U.S. Spoken language Reading language Radio and television
Low acculturation Lived in the U.S. 2-10 years Always spoke Spanish or

Spoke more Spanish than English

Spanish only Spanish only
High acculturation Lived in the U.S. more than years

Born in the U.S.

Spoke more Spanish than English

Spoke the same amount of Spanish and English

Spanish and English Spanish and English

To gain trust with potential participants, we offered transportation vouchers and onsite childcare. We reached out to local health networks, community health centers, clinics, hospitals, and cancer centers. To create a bilingual-bicultural environment, participants were told each session would be conducted in Spanish, English, or a combination of both languages, based on their own language preference.

Recruited participants represented different acculturation and language preferences. Each participant had experience looking for online cancer information on their own or with someone else, or carried a Latino patient caseload of at least 20 percent. Los Angeles was selected because of long established Latino communities representing various language preferences and acculturation levels. The diversity of health services available in the area allowed us to recruit different types of healthcare professionals, including certified medical professionals, lay health educators, and medical office staff.

Another User Group

While searching for participants, we found a new user group called promotoras de salud (promoters of health) that had not previously been visible to us. This group is somewhat similar to community health workers, who access online information and technology for use in health education programs targeting less acculturated Latinos, and implement programs using the train-the-trainer method.

Members of this community–—predominantly women with different acculturation levels and language proficiency—are trained to conduct bilingual health education and outreach in their own communities. Some are volunteers, while others are employed part-time.

They work in a variety of settings, including schools, churches, community clinics, homes, parks, community centers, and local health fairs.

Before conducting research for the en español site, we did not have an understanding of how promotoras were using online health information to help their communities navigate the U.S. healthcare system. We did not know the important role they play in the dissemination of online health information, and how they share their knowledge with offline Latino audiences.


As opposed to mainstream U.S. audiences who are interested in health content that is direct and geared toward the perspective of the individual, we found that our target users require something more than just translated content. Instead, they require content that has been adapted or “transcreated” to meet their cultural and linguistic needs.

While we obtained results for everyone in the recruitment matrix, some of the most interesting data came from the promotoras. The following findings and design principles demonstrate the needs of the population we studied:

Cultural Values

Respeto (respect) – Appropriate deferential behavior towards others based on age, sex, social position, economic status, and authority. Content written from the perspective of a doctor and images of doctors lent credibility to health information.

Familismo (family) – The prominence of interdependent networks within immediate and extended family members. Reflecting the importance of family, content should be geared toward the family and include images of families.

Confianza (trust) –Establishing a welcoming relationship. Content should include contact information for Spanish-speaking support personnel. The toll-free NCI Spanish phone support center was preferred.

Personalismo (personal connections, not institutional relationships) –  Descriptions of health organizations and institutions should have a community feel; NCI as “our institute” instead of “the institute.”

Health Beliefs

  • Addressing myths and health beliefs provides an opportunity to address fatalismo (fatalism). The belief is that cancer diagnosis leads to certain death. Homepage banner messages of hope and survivorship such as Siga adelande: la vida después del tratamiento del cáncer (Facing forward: life after cancer treatment) successfully challenged the perception of cancer as a death sentence.
  • Frequently asked questions on myths and beliefs are culturally appropriate ways to address stigmas related to disease. Participants first used content to answer their own questions about disease and then repurposed it for their trainees. A “Print this document” or “View/print PDF” button would help promotoras access and share.

Audio and Video Preferences

  • Audio functions can be used for self-education and to increase comprehension among Spanish speakers who have low literacy.
  • Including an audio download button allows the sharing of content with offline audiences.
  • Language pronunciation guides should be in audio format, rather than written, to avoid difficulties with phonetic pronunciation.
  • Audio content containing the voices of patients interacting with authoritative healthcare professionals gains trust (confianza).

Basic Understanding of Disease

  • Divide information into first-page basics about disease and second-level pages for more detailed medical information. Promotoras prefer starting with “What is cancer?” and then graduating to more technical content.

Language Access

  • Promotoras are experienced in determining the quality of Spanish translations and often compare the English and Spanish pages to decide on the quality of translation and its trustworthiness (confianza).They print and share satisfactory translations with offline Latinos; otherwise, they translate into Spanish.
  • Direct access to information in both English and Spanish via language toggles is important. Toggles that switch between identical pages are important so users can look up information in one language and then see it in another.

Plain Language

  • Language that’s simple to read and understand; shorter sentences and paragraphs
  • Concern about finding information suitable for people with low literacy in Spanish or English
  • Images
  • Access to images and graphic content is important for repurposing. Promotoras want to use graphics for their train-the-trainer programs.
  • Images help to identify and relate (confianza and personalismo) but do not serve as primary navigation.
  • Consistent with strong oral traditions in the Latino community, images tell stories about content.
  • Reflecting diverse Latino ancestries (Mexican, Central American, and Puerto Rican) is important for this group and creates a sense of confianza.


  • The left menu on the page serves as a navigation and orientation tool.


Although language is an important issue when working with the Latino population, equal attention needs to be dedicated to how Latinos differ from the mainstream U.S. population. Instead of translating from English to Spanish, online health information needs to be “transcreated” or adapted based on design guidelines that encompass the cultural and linguistic needs of this group, and serve as the foundation during adaptation of content from English to Spanish.

Groups that were previously considered offline depend on information intermediaries to find online health information and navigate the U.S. healthcare system. Promotoras first access health information to educate themselves and then repurpose content for their education programs. Based on these different needs, both designs and content should be created with a dual purpose.美国国家癌症研究所 (NCI) 于 2009 进行了一项用户调查,目的在于更好地了解诸如拉美裔等未获得周到服务的受众以及为其提供服务的医疗保健专业人员的在线健康信息需求。通过采用广泛的方法,我们聘请了一家招聘公司(有熟悉双语二元文化的职员),让其负责在加利福尼亚州的洛杉矶招聘具有不同的文化融入程度的拉美裔医疗保健专业人员。在寻找参与者时,我们发现了一个名为“promotoras de salud”(健康促进者)的新用户人群,而以前的调查中没有发现这一人群。 主流美国受众关心的是直接并迎合个人观点的健康内容与信息,与主流美国受众不同,该用户人群需要的不仅仅是翻译的内容。而且,他们还要求改编或“翻译创作”的内容满足其语言和文化需求。 这篇文章讨论了以下展示该用户人群需求的结论和设计原则: • 文化价值:尊敬、家庭、信任和个人联系 • 健康信念:宿命论、常见的关于神话和信仰的问题 • 音频和视频偏好:增强理解、可下载、语言发音指南、权威性意见 • 疾病的基本认识:第一层级内容和包含更多技术信息的第二层级内容 • 语言使用:等同的英语和西班牙语版本,可进行切换 • 通俗易懂的语言:便于语言文化程度低的人阅读 • 图片:具有较强的口头传统并反映多样化的祖先 文章全文为英文版

米国国立がん研究所(NCI)では2009年に、ラテンアメリカ系アメリカ人グループなど十分にヘルスケアサービスの恩恵を受けていない人々、およびサービスを提供する側であるヘルスケアの専門家における、オンライン上のヘルスケア情報のニーズについて理解する目的で、ユーザ調査を行った。我々は、包括的なアプローチを用いて、カリフォルニア州ロサンゼルスで、様々なレベルの文化変容の程度を持つラテンアメリカ系アメリカ人の医療関係者を募集するため、バイリンガルで双方の文化に詳しい現場スタッフのいるリクルート会社を利用した。そして参加者を探すなかで、以前の調査では明らかにならなかった「promotoras de salud(健康奨励者)」という新しいユーザグループを発見した。 直接的で自分の見方にマッチするヘルスコンテンツや情報に興味を持つ、米国の主流な閲覧者たちと違い、このグループでは単にコンテンツを翻訳した以上のものが求められており、コンテンツを言語または文化的なニーズに合わせて改作または「翻案」することが要求されている。 この記事は、このグループのニーズを示す以下のような結果やデザイン原則を説明している。 • 文化的価値:敬意、家族、信頼、個人的なつながり • 健康に関する信念:運命論、思い込みや通念に関して頻繁に尋ねられる質問 • 音声、画像に関する嗜好:理解度の向上、ダウンロードの可能性、言語発音ガイド、権威があるように聞こえる声 • 病気に対する基本的な理解:第一段階のコンテンツ、およびより専門的な第二段階の情報 • 言語面からのアクセス:英語版とスペイン語版の切り替え表示 • 平易な言葉:どちらの言語でも低レベルの読み書き能力しか持たない人が簡単に読めること • イメージ:説得力のある口承伝統と一致し、多様な民族性を反映すること 原文は英語だけになります

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