57.3, August 2010

Technical Communication in the Health Fields: Executive Order 13166 and Its Impact on Translation and Localization

Nicole St. Germaine-McDaniel


Purpose: The ongoing implementation of the tenets of Executive Order (EO) 13166 is helping change the focus of localization and writing for translation for technical communicators. In this article, I will discuss EO 13166; its impact on hospitals, clinics, and limited English proficient (LEP) populations; and how technical communicators involved in translation and localization help medical professionals comply with the law. I will provide best practice strategies for localization practices in the health care industry worldwide.

Method: This article employs a literature review of government documentation for Executive Order 13166, as well as hospital and clinic reports of current localization practices designed to increase compliance with EO 13166.

Results: The review of current practices indicates that much work remains to be done by technical communicators to help hospitals and clinics comply with EO 13166, especially in the areas of visual icons and other localization efforts.

Conclusion: The best strategies for localizing health care information include the following:

  1. Make the textual style of the information match that of the culture’s expectations.
  2. Research the preferences for graphics and color in medical documents for the target culture and use the preferred style in the documentation.
  3. Use widely recognized symbols.
  4. Use focus groups to test the localization strategy with representatives of the target culture.
  5. Consider the content of the documentation when localizing, not just the style and format.

Keywords: localization, graphic design, health, Executive Order 13166

Practitioner’s Takeaway

  • Technical communicators working in localization and health information are poised at the forefront to revolutionize the ways in which health care information is localized.
  • Wider use of focus groups (rather than reliance on traditional knowledge) has become essential for localization practices because of the trend toward localizing for smaller and more specific populations.
  • Technical communicators should consider the culture’s traditional views on medical information, wellness, and illness before they attempt to localize a document in terms of textual style, graphics, and color.


As Americans begin to focus on what constitutes fair and equal access to health care, questions arise about how language barriers affect access to health care services. According to the 2005 U.S. census, nearly one out of five Americans speak a language other than English at home; the resulting need for translation and interpretation services has given rise to legislation regulating which materials get translated and for which populations. Executive Order 13166 was designed to ensure that patients with limited English-speaking ability receive equal access to programs and health care through translation and interpretation services; it is a pivotal piece of legislation that is affecting how the medical profession treats the limited English proficient (LEP) population. Technical communicators and localization experts have assumed key roles in the effort to make health care information accessible to diverse populations in the United States.

In this article, I explore the impact of Executive Order 13166 and its effects on technical communication in the United States, and make recommendations for localizing health care information for LEP audiences, especially with regard to what technical communicators and localization experts can do globally to meet this emerging health communication crisis.

The Need for Health Information for LEP Populations in the United States

Each day, hospitals and clinics across the United States encounter limited English proficient (LEP) patients—persons defined by the U.S. Census Bureau as “speak[ing] English less than ‘very well’” (American Medical Association [AMA], 2006, p. 1). According to the American Community Survey (U.S. Census Bureau, 2005), more than 19% of Americans speak a language other than English at home. Many of the people who do not speak English at home (29% of Spanish-speakers, 22% of Asians and Pacific Islanders, and 13% of Indo-European language speakers) speak English “not well” or “not at all” (Hasnain-Wynia, Yonek, Pierce, Kang, & Hedges Greising, 2006, p. i). A similar survey conducted by the Health Research and Educational Trust (HRET) revealed that 12–23 million U.S. residents (4.5%–8.6% of the population) speak English less than “very well” (p. i).

In addition, HRET found that 80% of hospitals encounter LEP patients “frequently,” which was defined as at least monthly (Hasnain-Wynia et al., 2006, p. 2). This is a very large population of LEP patients who need translation (written language) and interpretation (oral language) services in a health care setting (p. 29).

Medical translation and interpretation issues are not confined to the United States. Worldwide, there are an estimated 191 million immigrants, and immigration rates have more than doubled around the globe in the past 50 years (Shah, 2008). The United States has taken only 20% of these immigrants, while Europe has absorbed 33%. This situation has created what many consider to be a global health information crisis (Shah, 2008). The European Union has unique challenges, particularly in the regulation of documentation for medical devices. The EU makes up 30% of the medical device market, but it is having problems balancing the need for regulations to meet the needs of all users against the cost and time required to do so:

Regulations controlling the manufacturing, marketing and usage of medical devices in the EU are forcing manufacturers to incorporate language translation and localization into global development strategies as individual Member States demand product information in the language of the local user. (Regulatory Language Requirements and the European Union, 2005).

The need for more translation and localization efforts in medical contexts has led to an increased involvement of technical communicators as writers and localization experts in the health fields in every developed country. Research indicates that many organizations are attempting to accommodate immigrant populations by offering a greater number of translated materials for their clients. Organizations and agencies such as the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control (CDC) have been translating and localizing health materials in greater numbers since President Bill Clinton signed Executive Order 13166 in 2000 (St. Germaine-Madison, 2007; St. Germaine-Madison, 2009). However, our understanding of LEP populations in the United States and their needs in the health care setting is incomplete, because until now the focus has largely been on industry. Executive Order 13166 has served as an impetus for technical communicators in the United States to study and serve these populations in a variety of health care contexts, and to examine localization needs within these contexts.

The United States is by no means the only developed country that is struggling to accommodate increasingly diverse populations in the health care context. However, it makes for an interesting case study, because until Executive Order 13166 came into being, the United States had no regulations regarding the required amount or quality of translations for medical contexts. Examining how technical communicators are reacting to the monumental demand for revision of health care documentation to comply with the executive order can help organizations facing this pressure judge their own progress and perhaps learn from the mistakes made and the unique approaches taken by some U.S. health care agencies.

Overview of Executive Order 13166

In August 2000, President Bill Clinton issued Executive Order 13166: Improving Access to Services for Persons with Limited English Proficiency. The intent of this order was twofold: (1) to better enforce an existing act and (2) to impose a new obligation for all federal agencies to meet these nondiscrimination standards.

Regarding the first intent, Title VI of the Civil Rights Act of 1965 “prohibits recipients of federal financial assistance from discriminating based on national origin by, among other things, failing to provide meaningful access to individuals who are limited English proficient” (Limited English Proficiency Web site). Title VI, in effect, mandates that “persons with limited English proficiency get meaningful access to federally funded programs” (Wong, 2004, p. 2). Many agencies, both public and private, receive some sort of federal assistance. In the context of health care, if a clinic, practice, or hospital accepts Medicaid or Medicare, this constitutes federal assistance, even if only one area of the hospital or clinic accepts federal funding (Schroeder, 2002). This includes most “hospitals, doctor’s offices, nursing homes, managed care organizations, state Medicaid agencies, home health agencies, health service providers, and social service organizations” (Sampson, 2006, p. 134).

Adapting to Executive Order 13166

In response to this mandate, hospitals, clinics, and other health care providers across the country have been scrambling to provide translated materials and interpreter assistance to their target users. Even 10 years later, many of these institutions are still working to increase their compliance with the order (Barrett, Dyer, & Westpheling, 2008), which means that technical writers and localization experts in the health care fields will have work for years to come just to make current programs, clinics, and hospitals compliant.

The language-assistance part of the order is intended to help LEP patients obtain federally supported health services. In the “Statement by the President,” Clinton expressed his desire to ensure equal access for LEP patients in the health care setting: “I am concerned that language barriers are preventing the Federal Government and recipients of federal financial assistance from effectively serving a large number of people in the country who are eligible to participate in their programs” (Clinton, 2000). According to Cindy Wong (2004), “This Executive Order provides ethical and statutory foundations for the provision of language assistance in health care on the basis of ensuring meaningful access to federally funded programs” (p. 4).

Helping LEP patients access programs such as Medicare and Medicaid is especially important, because LEP patients are less likely to enroll in federally funded programs and more likely to seek treatment at emergency rooms than to go to a clinic or urgent care facility. This situation has been called the “language barrier premium” (Sampson, 2006, p. 14). It drives up the cost of health care in the long run, because covering unpaid bills for ER services ultimately costs the consumer more than enrolling these patients in federal programs (Scalia, 2007, p. 14). Because the health care system is increasingly being held accountable for such costs, translated and localized patient materials, in conjunction with trained medical interpretation, have become attractive options for many organizations (Scalia, 2007; U.S. Department of Health and Human Services [DHHS], 2001). The intent of EO 13166 is, in part, to encourage LEP patients to seek appropriate assistance from programs designed to help them pay for their care.

In addition, LEP patients suffer when the health care system lacks proper support for other languages and literacy levels. The Language Services and Resource Guide published by the National Health Law Program states, “Language barriers may affect the delivery of adequate care through poor exchange of information, loss of important cultural information, misunderstanding of physician instruction, poor shared decision making, or ethical compromises (e.g. difficulty obtaining informed consent)” (Sampson, 2006, p. 11). Difficulties caused by language barriers have serious consequences for the LEP patient. For instance, the Centers for Medicare & Medicaid Services (CMS) found that language barriers have a significant effect on patients with limited English-speaking abilities. Owing to language barriers, these patients—

  1. Are less satisfied
  2. Have fewer visits to physicians
  3. Receive fewer preventive services
  4. Are less likely to return or to use clinics
  5. Score lower on health knowledge and understanding of diagnosis or treatment
  6. Have longer hospital stays (Wong, 2004, p. 4).

The Health Research and Educational Trust found that these patients also have a higher incidence of receiving expensive medical tests, and poor or no follow-up after procedures that require after-care (Hasnain-Wynia et al., 2006, p. 1); and the AMA blames language barriers for delayed diagnoses, misunderstanding of care plans, medication errors, misuse of health services, and lack of trust and confidence in the physician (AMA, 2006, pp. 1–2).

How Executive Order 13166 Affects Translation Practices

Executive Order 13166 aims to remedy the problems caused by language barriers by requiring the translation of all medical documentation that is part of a “vital” service. What is considered to be vital can vary, and agencies have at least partial jurisdiction over which documents are defined as vital. However, the FAQ page on the Limited English Proficiency Web site (www.lep.gov) defines “vital documents” as follows:

[A document] that contains information that is critical for obtaining federal services and/or benefits, or is required by law. Vital documents include, for example, applications; consent and complaint forms; notices of rights and disciplinary action; notices advising LEP persons of the availability of free language assistance; prison rule books; written tests that do not assess English language competency…; and letters or notices that require a response from a beneficiary or client.

However, the Web site acknowledges, “It may sometimes be difficult to draw a distinction between vital and non-vital documents, particularly when considering outreach or other documents designed to raise awareness of rights or services.” Further, many agencies and hospitals that want to be in compliance with the executive order have noted problems with informed consent. How can an agency or health care setting be sure that a patient truly understands the procedure he or she is about to undergo? Many entities, such as the National Health Law Program, recommend the use of printed patient materials to elaborate on an interpreter’s explanation or to substitute for an interpreter if necessary (Sampson, 2006). Materials such as the patient information pamphlets—written by medical writers and technical communicators and issued by the American College of Obstetricians and Gynecologists—that are handed out at OB/GYN offices can become vital tools for ensuring compliance with the order. While interpretation may be the preferred format, the translated pamphlets are necessary to fulfill the requirements of the law or to serve when appropriate medical interpretation is not available.

The second intent of the executive order was to impose a new obligation on all federal agencies to meet these nondiscrimination standards. Each federal agency must develop standards to comply with the order. Federal agencies such as DHHS, U.S. Citizenship and Immigration Services, and the Department of Justice have drawn up their own guidelines for translation and interpretation, and many organizations, such as the AMA, have developed additional guidelines for compliance (AMA, 2006). For DHHS, which oversees many of the programs and clinics that receive federal funding, nondiscrimination standards call for the recognition of—

  • Linguistic variation within a cultural group
  • Cultural variation within a language group
  • Variations in literacy levels in all language groups.

In 2000, the DHHS Office of Minority Health issued National Standards on Culturally and Linguistically Appropriate Services in Health Care (Perkins, 2003, p. 14). Of the 14 standards, all apply to language; these two apply specifically to written language:

  • Health care organizations must make available easily understood patient-related materials and post signage in the languages of commonly-encountered groups and/or groups represented in the service area.
  • Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. (p. 14)

DHHS recommends that all clinics and programs recognize these needs, and states that being culturally sensitive is just one of many strategies to meet the needs of the patient population and comply with federal standards (DHHS, 2001, p. 2).

Noncompliance with Executive Order 13166

Failure to comply with the EO can have potentially severe consequences for clinics, hospitals, and programs. In her article “Meeting the Needs of Patients with Limited English Proficiency” (2001), attorney Colleen M. Roberts explained that the government can terminate medical contracts with any physicians or agencies that do not comply with EO 13166 by not providing some sort of language assistance. Further, a legal precedent states that “health care providers not providing language assistance are negligent in facilitating clear communication and are ultimately obstructing informed consent, thus putting themselves at fault for malpractice suits where language services would have been appropriate” (Roberts, 2001, 71). In fact, DHHS has issued regulations prohibiting agencies that receive federal funds from engaging in the following activities:

  • Using criteria or methods of administration which have the effect of discriminating because of race, color, or national origin
  • Restricting the enjoyment of any advantage or privilege enjoyed by others receiving services through the same program.
  • Providing services or benefits to an individual that are different, or provided in a different way, from those provided to others.
  • Treating an individual differently from others in determining admission, enrollment, eligibility, or other requirement to receive services. (Sampson, 2006, p. 133).

If a person or organization files a complaint with the DHHS Office for Civil Rights, it will be investigated. If the health care organization or office is found guilty, it may lose its right to receive federal funds, such as Medicare, Medicaid, or State Children’s Health Insurance Program (SCHIP) funds (Sampson, 2006, p. 134).

Because of the severe consequences for noncompliance with EO 13166, most organizations have turned to technical communicators, including experts in localization and writing for translation (see Perkins, 2003; Sampson, 2006). Everything from the standards that the organization develops to meet EO 13166 to the actual documentation are developed in conjunction with localization experts, who help ensure that the documents meet the cultural preferences and linguistic needs (in terms of style and content) of the target audience. As a result, technical writers and localization experts have become the lynchpin for the success of these document revisions.

Beyond Translation: The Case for Localization

Executive Order 13166 and Localization

The role of localization has not gone unnoticed by DHHS and other health organizations, such as the AMA, which clearly mandate culturally appropriate translations as part of a multifaceted approach to culturally appropriate patient care. DHHS has instructed its agencies to use focus groups and community research to localize their printed information for target cultures, not just to translate it (DHHS, 2001, p. 19), and to make such localization practices an “integral part of strategic planning at all levels” (p. 25). The call for the localization of materials to comply with EO 13166 standards and to align with a culture’s rhetorical preferences and beliefs about wellness, illness, and the health care system in general has added to the need for technical writers working in this area.

DHHS and other health organizations continue to define ways in which their programs, hospitals, and clinics can become more culturally appropriate. In addition to the lack of available translation or interpretation, lack of localization has led to lawsuits based on alleged noncompliance with EO 13166. Wong (2004) says that the lack of culturally appropriate interpretations and translations has led to “higher rates of malpractice suits related to lack of clear communication regarding diagnosis, prescriptions, and treatment” (p. 4). One high-profile lawsuit was filed in 2002 by the New York Lawyers for Public Interest against two Brooklyn hospitals for failing to provide “appropriate” language assistance for Spanish speakers (Mozes, 2002; Pro-English Advocate, 2002). The University of Utah Health Science Center and the Maine Medical Center have both been sued for noncompliance with EO 13166. The cases were settled, but not without a great deal of negative publicity (Schroeder, 2002, p. 5).

Other localization issues have also arisen. For instance, the South Cove Community Health Center in Boston discovered that measurements had to be localized in instructions for Chinese patients, because “Chinese teaspoons” were much larger than the American teaspoon (DHHS, 2001, p. 18). What seem like small, insignificant differences can mean life or death for a patient. For this reason, DHHS is promoting the need for “practical, experience-based knowledge about the community being served,” which for the South Cove Community Health Center means ongoing training and certification through the Comprehensive Outreach Education Certificate Program. The sessions in this training include information for practitioners about localizing both oral and written health information; the program has been so successful that it is being replicated throughout Massachusetts (DHHS, 2001, p. 13).

The question at the heart of the lawsuits and problems with instructions and information is “What constitutes an adequate interpretation or translation?” Judgments in noncompliance lawsuits indicate that appropriate steps must be taken to ensure not only that language assistance is available but that it is appropriate for the population it claims to serve. This is not an easy proposition, but it is one that localization experts in the technical communication and health care fields are working to resolve.

The Role of Culture in Health Care

To localize health care information appropriately, technical communicators must be aware of how the patient’s culture can affect his or her perception of health and health care. Culture plays a major role in how patients experience their health care and in what constitutes “appropriate” health care for a specific population (Foucault, 1973, p. 16). Culture determines what constitutes illness and wellness, as well as how these states of being are treated and by whom (Forslund, 1996). Gary Kreps and Elizabeth Kunimoto (1994) say, “No matter how ‘rational’ the goals of a health care campaign are, from family planning to organ donation, cultural roots run deep and will influence audience member interpretation” (p. 97). For instance, Mexican-Americans consider social aspects as well as personal health before they decide to follow the advice of a physician. If the advice seems difficult to follow in light of a person’s social obligations, he or she is unlikely to comply (Browner & Press, 1997, pp. 126–127). A pregnant Mexican-American woman who is advised to avoid cigarette smoke for the health of her baby might not comply if family members would have to quit smoking to accommodate her needs (Committee on Health, Education, Labor, and Pensions, 2002).

This need for appropriate health care practices has been rolled into the nondiscrimination guidelines set forth by DHHS. The department held a contest in 1998 in which programs and clinics could be nominated for outstanding cultural practices. After the nominations were collected, DHHS published a manual, Cultural Competence Works (DHHS, 2001), that summarizes the nominated practices to demonstrate best practices for meeting the needs of a client population and complying with DHHS and federal guidelines. This guide explains how localized information and practicing health care in accordance with patients’ cultural beliefs combine to meet EO 13166 guidelines.

Different communities have different standards and beliefs about health practices, and DHHS recommends that practitioners honor both in their actions and printed materials (DHHS, 2001, p. 13). For instance, in some Hispanic cultures, it is believed that when the fontanel (“soft spot” of the baby’s skull) is sunken, it can be remedied by holding the baby upside down and giving it a gentle shake. Dominant-culture science maintains that a sunken fontanel is an indication of dehydration. La Clinica del Cariño Family Health center in Hood River, Oregon, resolved this issue by explaining to parents that in addition to the soft shake (which is not believed to hurt the infant), they should give the baby more liquids, such as breast milk or formula (DHHS, 2001, p. 13). In this way, cultural beliefs are not threatened but the infant’s health is safeguarded according to medical standards. DHHS lauds such compromises, because patients are more satisfied with their health care and more likely to follow instructions if the instructions do not run counter to their beliefs (p. 18).

In addition to specific health practices, the very concepts of “health” and “illness” differ widely among cultures—what one group might consider as well-being, another might consider as illness (Forslund, 1996; Kreps & Kunimoto, 1994). Forslund (p. 48) offers the example of a subtropical culture in which dysentery and malaria are common and, as a result, are not described in terms of “illness” but rather as normal (though unfortunate) states. Closer to home, many clinics and organizations, such as the Community Health Education Center of the Massachusetts Department of Public Health, have found that what constitutes “domestic violence” can differ among cultures. When the center director met with a focus group of Hispanic, Haitian, African American, and Puerto Rican women, she found that each culture had slightly different beliefs about what could be called “domestic violence.” A compromise was developed: Instead of defining domestic violence as verbal or physical abuse, a common definition was adopted that was appropriate for all the client cultures—being afraid of your partner because of his or her actions (DHHS, 2001, p. 14).

Brigitte Jordan (1997) refers to the differences in beliefs about wellness and illness as “cultural authority”—the probability that particular definitions of illness and wellness will be judged to be valid by a particular culture. In the case of domestic violence, women from cultures in which domestic violence was defined more narrowly might not seek treatment if the definition used in the literature did not match their cultural expectations (DHHS, 2001, p. 14).

Culture also affects how patients view health care documentation, which is in increasing demand as a stopgap measure when hospital interpreters are not available (Sampson, 2006, p. 93). It is clear that medical educational materials must be available for many populations, in many languages, and for various degrees of literacy (p. 93). Beyond simply supplying a translation, providers must ensure that the materials match cultural expectations for the medical genre, as well as the writing and graphics style preferred by the culture.

Localization of Text and Graphics for Medical Contexts

When technical communicators and localization experts modify a text for different language versions, they change (localize) the information to suit the target audience, meaning that they use a style, format, graphics, and even colors that meet the needs of the audience (Cronin, 2001; Yunker, 2003). In the United States such localization has not been regulated by any industry; however, the EU has stricter guidelines such as making illustrations for electrical plugs and other drawings of non-standard items reflect the appearance of those used for that particular member state (Regulatory Language Requirements and the European Union, 2005).

Text can be localized in many different ways—it might be shortened, expanded, or changed to accommodate the target culture’s preferences or to keep costs down. Similarly, graphics might be used instead of a written message (as in the case of a sign), added to support the target audience’s understanding of the subject matter, changed to accommodate the target culture’s preferences, or removed if they are not needed or to accommodate text expansion.


There are many ways to change text to accommodate a translation. All too often, text is simply cut. Translation is typically billed by the word, which makes reducing the amount of text an attractive option (Baker, 1992; Horton, 1993). In my own study of translated user manuals for household electronic appliances (St. Germaine-Madison, 2006), I noted a tendency to omit words in the Spanish translations of user documents for items such as DVD players and chest freezers. The omissions included condensing the wording in instructions, omitting safety information, and shrinking or omitting graphics.

However, because of the importance of health materials and the legal implications associated with EO 13166, a full localization effort is generally recommended before the text is translated, as opposed to merely cutting it to save money (DHHS, 2001). Almost all the literature from DHHS and state health agencies recommends that publishers of educational materials use focus groups or have representatives from the patient population serve on a board to ensure that patient information—such as consent forms, pamphlets, and signs—mirrors the expectations of the target culture not only in the terminology and translation but also the appropriateness for the culture of content, graphics, and even formatting (see AMA, 2006; DHHS, 2001; Sampson, 2006).

Focus groups and patient input can be very important for the localization of text, because stylistic preferences for text can differ widely across cultures. For example, textual style can differ in the following ways (St. Germaine-Madison, 2009; Tebeaux, 1999):

  • Indirectness. With regard to preferences in textual communication for health care, a culture can be categorized as high-context or low-context (Hall, 1976). Mexican and other Latin American audiences, as well as many Asian and West African populations, tend to be high-context. Barry Thatcher (1999) explains that the South American communication style, like other high-context styles, is “indirect, subtle, complex, evasive, and situational” (p. 183). On the other hand, low-context communications, such as those preferred in the United States by Anglo-Americans, “tend to be direct and easy to follow, valuing overt guidance in textual processing such as parallelism, organization, and symmetry” (p. 183).
  • Nonlinearity. Many cultures prefer their textual information to be nonlinear—grouped according to topic rather than chronologically or sequentially. For example, in 2005, CDC focus groups that examined Spanish-speaking preferences for brochures about HPV found a preference for information that was loosely grouped in a question-and-answer format rather than the traditional linear order preferred by English-speaking groups (St. Germaine-Madison, 2009). This is an issue in technical communication, because the field has traditionally valued direct, linear communication (Barnum & Li, 2006; Longo, 1998; Thatcher, 1999; Ulijn & St.Amant, 2000). Latin American and many other high-context cultures prefer nonlinear, topical grouping of information over linear, direct styles (Condon, 1985; Hall, 1976; Ulijn & St.Amant, 2000).
  • Formality. Many cultures tend to be more formal than Anglo-American culture. For example (speaking in generalities), many Latin American, Asian, and Middle Eastern professional documentation and correspondence tend to have a formal tone. Formality is related to “power distance,” which Geert Hofstede (2001) defines as “a culture’s willingness to accept differences in social levels” (p. 46). A formal culture might view the role of the physician as high above that of the patient and would expect the language in medical information to reflect that difference through its formality. Medical information that is too informal might not be perceived as credible (St. Germaine-Madison, 2009).
  • Emphasis on relationships. Another consideration is whether the culture is individual or collective in nature. Many Asian, Latin American, West African, and Middle Eastern cultures are collective, meaning that the needs of family and society are valued above those of the individual (Hofstede, 2001, p. 76). In a collective culture, communication is often “personal but diffuse in statement of purpose” (Tebeaux, 1999, p. 57).
    In many cultures, a tone of concern for the patient is an essential part of the physician-patient relationship. This relationship—called personalismo or personalism—is very important in Hispanic cultures in general, especially in the context of medicine. Patients seek a personal relationship with their physician, in which they can feel rapport and work in partnership to achieve health (Callister & Birkhead, 2002; Kreps & Kunimoto, 1994).
    In some cultures, physicians are not usually consulted unless an illness is untreatable by more traditional means; thus, they are perceived as a very strong source of authority, which contributes to the power distance between physician and patient. Unless the physician makes an effort to work with the patient on a personal level, the power distance is reinforced and treatment may not be effective (Committee on Health, Education, Labor, and Pensions, 2002; Kreps & Kunimoto, 1994). The tone of a medical document can go far to help establish a relationship of trust, which is particularly important when the physician or practitioner cannot communicate directly with the patient because of a language barrier.
  • Tone of uncertainty. Cultures also differ in how they view the future (Kenna, 1994). The issue of uncertainty is related to the cultural dimension of uncertainty avoidance, which Hofstede (2001) defines as “the extent to which the members of a culture feel threatened by uncertain or ambiguous situations” (p. 167). Cultures that display high uncertainty avoidance (such as the Mexican culture) may prefer more information in their medical documents—such as a more detailed explanation of the risks involved in a procedure or disease—because they have a lower tolerance for ambiguity (St. Germaine-Madison, 2009).


In addition to textual style, the graphics and visual elements of a text or sign are important. Graphics in translations and to assist in wayfinding, as well as the use of signs and symbols to help LEP patients, have been in high demand for hospitals and clinics because they are (in theory) understood by speakers of most languages and they reduce the costs associated with translation and localization (Sampson, 2006, p. 93). Technical communication scholars, most notably Horton (1993), have lauded the use of simple graphics as a key aspect of localizing a document, because they can cover for a problematic or faulty translation, or make a translation more useful to a wider audience (p. 683). Graphics are a key component of most translations, regardless of audience preferences.

Wayfinding Symbols

The need for wayfinding symbols has become so pressing for hospitals and clinics that Hablamos Juntos, along with other localization organizations, are working on the growth and development of a set of universal health care symbols (www.hablamosjuntos.org). Globally, the use of symbols and wayfinding icons is also a concern. The European Committee for Standardization (CEN) is working on a set of symbols to be used in documentation and signage in European Union countries. Until a truly universal system is adopted, some organizations, such as the U.S. Department of Transportation and Hablamos Juntos, have developed systems of signs that are available free of charge, thanks to a grant from the Robert Wood Johnson Foundation (Sampson, 2006, pp. 94–98). For examples, see figure 1.

Figure 1: Examples of wayfinding symbols developed by Hablamos Juntos (www.hablamosjuntos.org).

Examples of wayfinding symbols

In addition to wayfinding symbols, technical communicators and localization experts must consider the use of graphics in other types of health information, such as brochures and information sheets. The kinds of graphics (see Forslund, 1996; Quiye, 2000), their placement, the use of color, and the subject matter depicted are all subject to scrutiny to determine whether the original graphics need to be revised for users from another cultural or linguistic group (see Horton, 1993; Kostelnick, 1995).

Graphical Preferences

Preferences for certain types of graphics or certain subject matter can vary widely by culture. For example, according to information scholars have gathered about Mexican and Mexican-American cultures in general, in the context of medical information, women of Mexican descent often prefer photographs of people over line drawings; in social contexts, they prefer photographs of people of similar heritage over photographs of individuals (Forslund, 1996; Ogilvy Public Relations Worldwide, 2005). Forslund credits the visual tradition of some of the Mexican literary genres for this preference, but it may also have its roots in the holistic nature of traditional Mexican views of medicine and wellness (Callister & Birkhead, 2002; Kreps & Kunimoto, 1994). Many Mexican and Mexican-American patients believe that no illness or condition can be treated without considering the needs of the patient and the patient’s health as a whole (Callister & Birkhead, 2002). This may contribute to their desire to see photographs of actual people undergoing treatments rather than line drawings showing the affected body parts, which are preferred by dominant-culture American society (Forslund, 1996).

The Use of Color

The colors used in the information affect how patients perceive it. According to Horton (1993), color is usually also a consideration in the localization of graphics. For example, organizations interested in localizing for a Hispanic audience should use more color and more vibrant color in the design of materials (Yunker, 2003). In fact, localization experts like Yunker say that a failure to use color in the design can actually jeopardize the credibility of information products in the eyes of some users. In the CDC campaign to inform the public about HPV, color was found to play a large part in Spanish-speaking users’ preferences in educational materials (St. Germaine-Madison, 2009). Less is known about the role of color in health care documentation for other cultures, but many cultures probably have their own preferences; therefore, it is important to localize information for color preferences as well as graphical preferences.

Executive Order 13166 and Its Impact on Technical Communication

Technical communicators and localization experts are on the front lines of the movement to make health care information accessible to people from many different cultures. As a result of EO 13166 and other developments—such as passage of health insurance reform legislation and changes to the Medicare system that involve greater choice for participants—organizations, hospitals, and other institutions are clamoring for more and better translated and localized materials for their clients (Scalia, 2007, p. iii). As our concepts of “available” and “fair access” continue to evolve in the national debate on health care, technical writers will continue to shape the practices for writing and localizing health care information.

The ramifications of EO 13166 are still being felt nationwide. Although the order was implemented 10 years ago, it is still being integrated into hospitals and clinics because of the sheer magnitude of the materials and the cost of localizing and translating them (Barrett et al., 2008). This situation has left medical writers and localization specialists scrambling to provide “appropriate” translation and localization services in the health care setting, particularly in states with high concentrations of non-native speakers. In Texas, for instance, 10% of residents claim Spanish as their first or only language, according to the 2000 Census. That means that 6.7 million people in Texas alone have a potential need for medical interpreters or translations of health care documentation such as brochures about medical conditions or patient information fact sheets.

The shortage of qualified medical interpreters means that all “vital” medical documentation must be translated; this requirement has placed technical communicators and localization experts on the front lines of the effort to make health care documentation accessible to the LEP population. As noted earlier, the question often arises of what constitutes vital information. DHHS (2001) defines it as patient consent forms and instructions for care, but other entities, such as the National Health Law Program (NHELP), claim that these documents are not enough (Barrett et al., 2008). According to a recent study conducted by the National Senior Citizens Law Center (NSCLC), even when appropriate medical interpreters were available, Spanish-speakers were able to access an interpreter only 71% of the time, and the success rate of other language groups was much lower (e.g., 41% of the time for Mandarin Chinese speakers) (Scalia, 2007, p. iv).

As a result of the shortage of trained and appropriate interpreters, many organizations, such as the NSCLC and the National Council on Interpreting in Health Care, recommend that translated printed materials be made available even for clients who have had the opportunity to speak with an interpreter (Downing & Roat, 2002; Scalia, 2007, p. iv). While medical interpretation may be the preferred format, translated pamphlets are necessary to fulfill the requirements of the law, to substitute for medical interpreters, and as a reference or reading aid for patients (Scalia, 2007, p. iv). In many medical care situations, translated materials are the only source of language-appropriate health information for LEP patients. This means that agencies, hospitals, and clinics are mandating the translation of a wide array of patient information materials, and technical communicators have been largely responsible for localizing these materials and preparing them for translation.

Technical communicators and localization experts are also in great demand to design graphics for wayfinding materials, such as signs, and for printed health care information, as well as designing the layout of the information for the target audience (www.hablamosjuntos.org). The appropriate use of signs and graphics may reduce the costs associated with medical translation and interpretation by augmenting the information or by using universal symbols that are recognized by LEP patients from many language groups.

Because of the great need for translated and localized materials to help hospitals, clinics, and other organizations comply with the nondiscrimination tenets of EO 13166, technical communicators working on the localization of health care materials have a large role to play in ensuring that LEP patients receive adequate health care according to the law. The global pressures of immigration continue to influence regulatory legislation and localization efforts in the EU and other developed nations. The need for materials positions technical communicators at the forefront of the movement for culturally appropriate health care information.

Conclusion: A Summary of Best Practices

Technical communicators and localization experts working in health care settings worldwide need a set of principles or best practices to guide their attempts to serve their local populations. However, complicating the issue, each country or region and even each organization seems to have its own idea of what constitutes a best practice for localizing information for patient groups in its service area. For example, the European Union specifies which documents must be localized and translated with a set of guidelines, while the United States leaves the decision and guidelines up to individual organizations. However, a few common strategies have emerged in the discussion.

Strategy 1: Make the textual style of the information match that of the culture’s expectations. Research the culture using Geert Hofstede’s (2001) and Edward T. Hall’s (1976) cultural dimensions, as well as the preferred style of writing for the target culture. Information on the ways in which cultures differ is available and, as the work of Tebeaux (1999) and others suggests, highly applicable to practical writing strategies for global contexts.

Strategy 2: Research the preferences for graphics and color in medical documents for the target culture and use the preferred style. In some countries—such as China, Mexico, and the United States—specific information is available regarding the preferred format of graphics in various contexts. However, on-the-ground research is needed for many countries. Focus groups and subject matter experts can help.

Strategy 3: Use widely recognized symbols. When information must be localized for a variety of cultures and language groups, as in signs, use widely recognized symbols such as those developed by Hablamos Juntos and the Department of Transportation (Hablamos Juntos, 2005; Sampson, 2006, pp. 94–98). These free symbols appeal to a wide variety of language groups.

Strategy 4: Use focus groups. Many organizations agree that focus groups are the best, most cost-efficient way to localize health care information for a particular patient population. The nature and scope of the focus group will vary depending on how widely distributed the information will be and how many target cultures the writer is hoping to reach. Many organizations, such as the Community Health Education Center of the Massachusetts Department of Public Health, conduct small, locally based focus groups for information from the hospital or clinic, while larger organizations, such as CDC, conduct focus groups across the country to ensure that they are capturing a wide array of opinions for information that will be published nationally (DHHS, 2001, p. 14; Ogilvy, 2005). Focus groups can provide valuable information about preferences for text and graphics when the information is not available through research.

Strategy 5: Consider the content, not just the style and format. Recognize that the localization of textual health care information is a sensitive undertaking, with much at stake for both the patient and the hospitals and clinics involved. Localizing information goes beyond a simple consideration of language, style, and graphics; the information must match the culture’s expectations for topics that can be covered and its perceptions about health and health care in general (Callister & Birkhead, 2002; Forslund, 1996; Kreps & Kunimoto, 1994).

It is imperative to ensure that medical information is not just translated correctly but is also culturally appropriate. The consequences for not connecting with an LEP population are profound—from expensive and time-consuming lawsuits for the hospital or clinic to patient injury and even death. With time and research, technical communicators, through their efforts to improve the quality of translation and localization efforts, are poised to have a positive impact on the health and welfare of millions of LEP patients in health care settings.


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About the Author

Nicole St. Germaine-McDaniel is the chair of technical and business writing at Angelo State University and a senior member of STC. She is the recipient of a 2009 Frank R. Smith Distinguished Journal Article Award for her article “Localizing Medical Information for U.S. Spanish-Speakers: The CDC Campaign to Increase Public Awareness about HPV,” which appeared in the August 2009 issue of Technical Communication. Her research interests include technical communication for a Spanish-speaking audience and technical communication for the health fields. Contact: nstgermaine@angelo.edu