Implementing interpreter training for dementia assessments at national scale using the RE-AIM framework: A mixed-methods evaluation

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Professional interpreter support is essential to ensure equitable access to accurate dementia diagnosis and care. To address this need, a nationally specialised online, self-paced training on dementia and cognitive assessments was developed for interpreters. Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, this article reports on the training’s implementation. Specifically, it explores the training’s reach, barriers and facilitators to adoption, effectiveness in improving interpreter-mediated assessments, and potential for long-term maintenance. Methods Between 24 November 2023 and 12 December 2024, the online self-paced training was rolled out to interpreters nationally across Australia. Implementation was supported by industry study partners, including interpreter agencies, advocacy organisations, a technology partner, and the national accreditor for interpreters. A mixed-methods evaluation was undertaken. Quantitative monitoring captured the training’s reach, uptake, and successful completion. In parallel, qualitative interviews were conducted with 24 interpreters who completed the training, 6 managers from interpreter agencies, and 16 clinicians who worked with interpreters to undertake cognitive assessments. Quantitative data were descriptively analyzed, and qualitative data were analyzed using the framework method. Results 865 interpreters, representing 14.4% of Australia’s active interpreter workforce, completed the training. Interpreters and agency managers reported that the training improved interpreter practice and confidence. In contrast, clinicians were unaware of the training. Barriers to uptake included time constraints, technical issues and limited computer literacy, and the perceived difficulty of the content for some participants. Key facilitators included ease of access (being online and no cost), incentive of professional development points, a straightforward final assessment, and administrative support. The training has now been made freely and permanently available on the national accreditation authority’s website. Conclusions This world-first study demonstrates a scalable approach to delivering interpreter training for dementia assessments, with the potential to enhance the accuracy and timeliness of diagnosis for ethnically and linguistically diverse people living with dementia. Interpreter training cognitive assessment dementia healthcare equity ethnic diversity Introduction Australia, like other high-income countries such as those in Europe [ 1 ] or Canada [ 2 ], has an increasingly ethnically diverse and ageing population [ 3 ]. These demographic shifts are contributing to a rise in age-related conditions, including dementia, among ethnically diverse older people. By 2056, dementia prevalence will increase by 67% among overseas-born Australians compared with 58% among those born in Australia [ 4 ]. To meet the needs of this growing cohort, health and aged care services must prioritise culturally appropriate care, including access to professional interpreter support. This is particularly important during cognitive assessments for dementia, as aphasia often first appears in non-primary languages before affecting primary languages [ 5 ]. During cognitive assessments, interpreters play a vital role in mediating both verbal and non-verbal communication between patients and clinicians, facilitating timely and accurate diagnosis, access to treatment, and post-diagnostic supports [ 6 , 7 ]. Without specialised training, however, interpreter involvement can lead to reduced satisfaction among patients and clinicians, increased conflict, and diagnostic delays [ 8 , 9 ]. Interpreting cognitive assessments requires a very high level of verbal and linguistic accuracy, with inaccurate or missed speech potentially compromising the assessment result [ 10 , 11 ]. Given that cognitive assessments require a high degree of linguistic precision, even small errors or omissions in interpreting can compromise assessment outcomes. In our previous work, interpreters reported that people with dementia represented a growing proportion of their clientele, and that they sought specialist training in mediating cognitive assessments for dementia [ 12 ]. Recognising this need, The Improving Interpreting for Dementia Assessments (MINDSET) study codesigned [ 13 ] and trialled [ 14 ] a specialized online training program on dementia and cognitive assessments for interpreters. The trial engaged 126 interpreters across six languages commonly spoken by older Australians (Arabic, Cantonese, Greek, Italian, Mandarin, and Vietnamese). Findings from this single-blind, parallel-group randomized clinical trial showed significant improvements in the quality of interpreter communication at 3 months among those who completed at least 70% of the training [ 14 ]. Building on these results, the training was subsequently scaled for national implementation, making it available to all interpreters in Australia. The implementation was guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework [ 15 ], a widely used framework in implementation research that evaluates not only effectiveness but also real-world translation [ 15 ]. RE-AIM enables systematic assessment of who benefits from an intervention, how it is adopted across settings, the consistency of its delivery, and its sustainability over time [ 16 ]. This comprehensive perspective provided a robust foundation for translating the outcomes of the MINDSET trial into routine practice [ 15 ]. The aim of this article is to report on the implementation of the MINDSET training, focusing on its reach, barriers and facilitators to adoption and implementation, real-world effectiveness in supporting interpreter mediated cognitive assessments for dementia, and potential for long-term maintenance. Methods Design A mixed-methods design was applied. Quantitative monitoring captured the training’s reach, uptake, and completion rates while qualitative interviews explored the experiences of interpreters who completed the training, their agency managers, and clinicians working with interpreters during cognitive assessments. The protocol is published [ 17 ] and the Standards for Reporting Implementation Studies (StaRI) reporting guideline was followed [ 18 ]. Ethical approval was obtained from the University of Western Australia Human Research Ethics Committee, with governance approval provided by the National Ageing Research Institute. Participants all provided informed consent prior to completing the training and interviews. Context Interpreters represent a largely invisible and understudied workforce. In Australia, they often work under challenging conditions characterised by insecure employment, variable pay rates, and high emotional demands [ 19 ]. Most interpreters are engaged on a casual or per-assignment basis across multiple agencies, with limited access to stable income, paid leave, or professional development opportunities [ 20 , 21 ]. Within health and social service settings, interpreters also face significant pressures, including strict time constraints, exposure to sensitive or traumatic content, and the need to rapidly adapt to different languages and cultural contexts [ 22 ]. These working conditions can contribute to stress, burnout, and workforce shortages, underscoring the importance of providing greater support, recognition, and professional development opportunities for interpreters [ 19 , 22 , 23 ]. Targeted ‘sites’ and populations Given the casualised nature of the Australian interpreter workforce, this study was community-based and conducted online across Australia between 24 November 2023 and 12 December 2024. The evaluation included interpreters, their managers, and clinicians. Interpreters, the target of the training intervention, were eligible if they: (i) interpreted in any spoken or signed language, ii) lived in Australia, and iii) had internet access. No restrictions were placed on interpreting qualifications or experience, and students were eligible to participate. Interpreter agency managers and clinicians were the focus of the implementation evaluation. Managers were eligible if they (i) worked in leadership roles at public and private organizations, and (ii) had oversight of interpreter professional development. Clinicians were eligible if they worked (i) in health settings offering diagnostic dementia services (e.g., memory clinics, hospitals), and ii) with interpreters during cognitive assessments for dementia at least once a month. Intervention The four-hour training was co-designed [ 13 ] and incorporated written materials and instructional videos alongside links to key external readings. It addressed five core domains: dementia knowledge, cross-cultural communication, briefings and debriefings, interpreting skills, and interpreting ethics [ 13 ]. Implementation strategies To promote the training, it was freely available, online, and self-paced. Interpreters could claim up to 20 professional development (PD) points upon successful completion that could be counted towards the renewal of their credentials for three years from the National Accreditation Authority for Translators and Interpreters (NAATI), Australia’s national standards and certifying body for translators and interpreters. It was comprehensively marketed over 12 months through two launches (online and in-person at a national interpreter conference); a social media campaign with 43 posts shared across LinkedIn, Facebook, and X; and notifications about the training in industry newsletters, electronic mailing lists, and e-bulletins. We also asked our industry partners – i.e., three interpreter agencies (one federal, one state, one private company), two advocacy groups, a technology partner, and NAATI – to directly contact interpreters registered with them to alert them about the training. Hospital interpreting services, university and vocational course coordinators, and private interpreter agencies were also contacted to request they promote the training to their interpreters. To facilitate enrolment in the training, interpreters expressed their interest via a quick-response code linked to a Microsoft form that included eligibility screening questions, a consent form, and basic demographic information. They were then directed to an online link to register for and access the online training. This was regularly monitored by the research team who provided technical support to anyone who could not register or had not registered following completion of the form. Mass emails were used to remind participants who had expressed interest to enrol in the training. To encourage completion of the training, weekly reminder emails were sent to enrolled participants. A 1-month time limit was advertised to enhance completion; however, interpreters were always given an extension if requested. The original trial assessment – a 30–40-minute video simulation of a cognitive assessment graded by assessors who are also NAATI test examiners and educators familiarised with the NAATI testing rubrics – was removed from this iteration of the training due to its cost, time demands, and limited availability across languages. Instead, a single end-of-training quiz was introduced (Additional file 1), allowing automatic scoring, immediate feedback, unlimited retakes, and the option to download a completion certificate. Outcomes Table 1 described how RE-AIM [ 15 , 16 ] was operationalised in our implementation outcomes. Table 1 RE-AIM implementation outcome measures RE-AIM dimension How it was assessed Type of data (qualitative/quantitative) Reach Rates and representativeness of interpreters who enrolled and completed the training compared to those who did not. Quantitative Effectiveness • Multiple-choice assessment quiz at training completion • Qualitative interviews with interpreters, managers, and clinicians. Quantitative Qualitative Adoption Evaluated through interpreter and manager interviews, focusing on barriers and enablers to adoption of the training. Qualitative Implementation • Rate of completion and time spent on the training. • Interviews on the perceived value, quality, and impact of the training. Quantitative Qualitative Maintenance Described through collaborations built to promote the training and sustain its availability through industry partnerships beyond the lifecycle of the MINDSET project. Qualitative [INSERT Table 1 HERE] Procedures Semi-structured interviews were conducted online via Microsoft Teams by NC, SM, and MC. Questions focused on understanding if the training was perceived to improve interpreter communication, impact practice, and clinician satisfaction (see Additional file 2). Interpreters and clinicians were remunerated for their time at their average hourly professional rate. Sample size We aimed to enrol 2,405 interpreters in the training, approximately 70% of NAATI accredited interpreters in the above-mentioned six languages (Arabic, Cantonese, Greek, Italian, Mandarin, and Vietnamese n = 3,400). Once 30% of the sample had been screened (n = 722), we invited 140 interpreters who had enrolled in the training to participate in an interview. Purposive sampling was used to ensure participants were diversified by sex, language, location (state, urbanicity), and NAATI credentialing. Concurrently, we also invited 10 interpreter agency managers to participate in an interview. Once 50% of the sample had been screened (n = 1,203), clinicians working in catchment areas with high ethnic diversity were invited to be interviewed using a combination of purposive and snowball sampling. Again, we sought to diversify our sample by profession (e.g., geriatrician, psychiatrist, nurse, allied health) and state. Analysis Quantitative data were descriptively analysed in SPSS Version 29.0.1.0. Interviews (up to one hour in length) were audio recorded and transcribed verbatim by an external transcription service, with identifying data removed. Using the framework method [ 24 ], two researchers (NC and BB) independently coded two interviews, then met to discuss their codes from which a working schema was developed through consensus. Using this scheme, NC and MC replicated the process on two additional transcripts, further refining the schema and developing a draft analytical framework. The cycle was repeated twice more involving NC, SM, and BB before the analytical framework was finalised. NC then coded all transcripts in NVivo version 12.6.0.959. Data were initially analysed inductively and then text and code were mapped against the predetermined RE-AIM domains, specifically effectiveness, adoption, and implementation. In this way, a multidisciplinary team ensured agreement on the themes and coding of text. Any differences between researchers were negotiated and if necessary, regrouped and recoded until consensus was reached. Such steps ensure consistency [ 25 ]. Their interpretations and summaries were also continuously presented to the wider team for verification and further refinement. We adopted key strategies to enhance study rigor. Dependability and the ability to replicate this study was enhanced using an audit trail, a clear analytic process and peer debriefing [ 25 ]. Credibility and confirmability was achieved through reflexivity, transparency in thorough team discussion, and the use of verbatim quotes [ 25 ]. Thus, data trustworthiness was established through triangulation, audit trails, and consensus validation [ 25 ]. Results Characteristics of participants Overall, there were 2,424 expressions of interest to complete the training via the online form, of which 420 did not consent to further participation in the study, 369 did not live in Australia, 90 were not an interpreter, and 158 had already participated in the MINDSET trial. This left 1,387 eligible participants, most of whom were women (1,046, 75.4%), with a mean age of 49.5 (± 13.8), and from New South Wales (482, 34.8%) (Table 2 ). Eligible participants worked in 103 languages, with Mandarin (17.6%), Arabic (11.4%), and Auslan (8.3%) being the most common. Table 2 Characteristics for interpreters who registered for the MINDSET training Participant characteristics (n = 1387) Gender, n (%) Female 1046 (75.4) Male 327 (23.6) Non-binary 7(0.5) Prefer not to say 7(0.5) Age Mean (SD) 49.5 (13.8) Median 49.0 Range 18–83 Location, n (%) New South Wales 482 (34.8) Victoria 428 (30.9) Queensland 171 (12.3) South Australia 98 (7.1) Western Australia 94 (6.8) Tasmania 50 (3.6) Northern Territory 35 (2.5) Australian Capital Territory 18 (1.3) Not specified 11 (0.8) NAATI credential status, n (%) Certified Interpreter 524 (37.8) Certified Provisional Interpreter 552 (39.8) Recognised Practicing Interpreter 67 (4.8) Specialised Health Interpreter 5 (0.4) None 225 (16.2) Other 14 (1.0) Highest level of education, n (%) High school graduate 42 (3.0) Certificate III-IV 45 (3.2) Diploma or Advanced Diploma 245 (17.7) Bachelor Degree 392 (28.3) Bachelor Honours Degree, Graduate Diploma or Graduate Certificate 133 (9.6) Postgraduate Degree (Masters or Doctoral) 524 (37.8) Other 5 (0.4) Highest level of education in interpreting, n (%) None 368 (26.5) TAFE Short Course 89 (6.4) Diploma or Advanced Diploma 481 (34.7) Bachelor Degree 102 (7.4) Bachelor Honours Degree, Graduate Diploma or Graduate Certificate 96 (6.9) Postgraduate Degree (Masters or Doctoral) 227 (16.4) Other 22 (1.6) [INSERT Table 2 ] Alongside, we interviewed 24 interpreters who worked in established (e.g., Greek, Italian) and emerging languages (e.g., Oromo, Ukrainian), six interpreter managers, and 16 clinicians including geriatricians (n = 6), clinical neuropsychologists (n = 4), social workers (n = 3), physiotherapist (n = 1), psychiatrist (n = 1) and occupational therapist (n = 1) (Table 3 ). Most participants were based in urban areas, from Victoria or New South Wales, the two most populous and multilingual states in Australia. Table 3 Interview participant characteristics Interpreters Interpreter managers Clinicians n(%) Sex female n(%) 18(75%) 4 (67%) 12 (75%) Urban-based 20 (83%) 5(83%)^ 16 (100%)* State ACT NSW NT QLD SA TAS VIC WA 1(4%) 6(25%) 0 1(4%) 4(17%) 2(8%) 7(29%) 3(13%) 0 1(17%) 1(17%) 0 0 0 4(67%) 0 0 2(13%) 0 1(6%) 0 0 13(81%) 0 Years of experience in role (Median) 19 2.4 12.5 ^one manager reported working in an outer-regional setting; * one clinician reported working in both an urban and an inner-regional setting. [INSERT Table 3 ] Reach Of 1,387 eligible participants, 1,185 enrolled in the training, and 867 completed it (defined as finishing > 70% of the training including the quiz; 857 completed 100% of the training). 301 (25.4%) completed ≤ 25% of the training, 15 (1.3%) 26%-50%, and 2 (0.2%) 51%-70%. For those who completed the training, the median time taken to complete the training was just over one week, although for some participants completion occurred over several months (median = 7.81 days, range < 1-321 days). Those who completed the training were more likely to be female (χ 2 [1, n = 1091] = 4.10, p = .043); and were older ( t (1098)=-3.21, p = .001). Significant differences in NAATI credential status were observed between those who completed the training and those who did not (χ 2 [3, n = 1088] = 9.97, p = .019), examination of standardised residuals indicated this was driven by those with no NAATI credentials not completing the training. In contrast, there were significant differences in highest level of education between those who did and did not complete the training, however, examination of standardised residuals indicated a diffuse pattern with results not driven by any particular categories (χ 2 [3, n = 1095] = 8.22, p = .042). There were no significant differences in state of residence between those who completed the training and those who did not (χ 2 [7, n = 1094] = 12.04, p = .099). Differences in rates and representativeness of interpreters who enrolled and completed the training compared to those who did not is described in Table 4 . Table 4 Characteristics of interpreters who enrolled and did and did not complete the training. Participant characteristics Training completers Training non-completers p 867 318 Missing demographic data 71 13 Gender, n (%)^ .043 Female 623 (71.9) 218 (68.9) Male 168 (19.4) 81 (25.5) Non-binary 3 (0.3) 2 (0.6) Prefer not to say 2 (0.2) 3 (0.9) Age .001 Mean (SD) 50.19 (13.59) 47.22 (13.97) Location, n (%) .099 New South Wales 279 (35.3) 98 (32.3) Victoria 224 (28.3) 116 (38.3) Queensland 104 (13.1) 34 (11.2) South Australia 57 (7.2) 19 (6.3) Western Australia 58 (7.3) 16 (5.3) Tasmania 32 (4.0) 8 (2.6) Northern Territory 24 (3) 6 (2) Australian Capital Territory 13 (1.6) 6 (2) NAATI credential status, n (%) ^ .019 Certified Interpreter 311 (39.1) 97 (31.8) Certified Provisional Interpreter 308 (38.7) 119 (39) Recognised Practicing Interpreter 39 (4.9) 20 (6.6) Specialised Health Interpreter 4 (0.5) 1 (0.3) None 122 (15.3) 67(22) Other 12 (1.5) 1 (0.3) Highest level of education, n (%) ^ .042 High school graduate 17 (2.1) 13 (4.3) Certificate III-IV 28 (3.5) 12 (3.9) Diploma or Advanced Diploma 133 (16.7) 57 (18.7) Bachelor Degree 237 (29.8) 69 (22.6) Bachelor Honours Degree, Graduate Diploma or Graduate Certificate 80 (10.1) 25 (8.2) Postgraduate Degree (Masters or Doctoral) 299 (37.6) 125 (41) Other 1 (0.1) 4 (1.3) Top 5 interpreting languages, n (%) Mandarin, 138 (17.4) Mandarin, 43 (14.1) Arabic, 85 (10.7) Auslan, 37 (12.1) Auslan, 71 (8.9) Arabic, 30 (9.8) Vietnamese, 52 (6.5) Vietnamese, 24 (7.9) Spanish, 47 (5.9) Spanish, 23 (7.5) ^Due to small sample sizes in the non-binary and prefer not to say categories, statistical testing on gender was only performed on males/females. Due to small sample sizes in NAATI credential status categories, the specialised health interpreter category was combined with the certified interpreter category, and the ‘other’ category was removed from the analysis. Due to small sample sizes, high school graduate was combined with certificate III-IV, Bachelor Degree was combined with Bachelor Honours Degree, Graduate Diploma or Graduate Certificate degree and ‘other’ was not included in the statistical analysis. Differences in languages were not statistically analysed due to the large number of categories, and small sample sizes for each. Instead, the top 5 languages are presented for descriptive purposes only. [INSERT Table 4 ] Effectiveness Results of the assessment quiz on completion of the training indicated a high overall score, with an average of 25.06 out of a possible 29, and a high overall pass rate (99% of participants), based on all attempts at the quiz. As participants had unlimited attempts to re-take the quiz, the average score and pass rate were higher when considering their highest attempt, with an overall average of 25.40, and pass rate of 99.8%, respectively. Approximately half of the interviewed interpreters had undertaken a cognitive assessment since completing the training, and most reported feeling well prepared for these sessions. After the training I had [on] two occasions interpreted for the dementia patient and also family members. Yes, and some of the knowledge did help. [...] I know how the assessment works and how to communicate to a dementia patient and try to like make my interpreting as accurate as possible by like, sometimes parroting the way they were talking. So that we can make an accurate diagnosis (Mandarin interpreter, 19 years’ experience) . Interpreters said they valued the structured learning format, which contrasted with the ad hoc knowledge typically acquired on the job, and noted it was especially beneficial for those without a health background. Managers reinforced that the training helped interpreters appreciate the complexity of the area, and that it was a sensitive topic that required attention. Several interpreters mentioned that the training would be especially important for new interpreters to provide foundational knowledge, and some even suggested it should be a requirement to get accreditation. It [training] has a lot of benefits. Personally, if I begin from myself, I don't have that information at all. The science, what can I do, so knowing those all information, it helps me to understand […] So if you don't know what cognitive assessment, sometimes we don't know during interpreting, sometimes I don't know the topic, so I have to ask the doctor what does it mean? ( Amharic and Oromo interpreter, years’ experience ). Some of the things were a bit basic for more advanced interpreters, I think people have been doing it for a long time. But I think it's particularly useful for the ones that are just starting ( Interpreting Agency Manager 1, 1 year of experience) . Dementia, voluntary assisted dying. These are all very difficult settings for interpreters, whether it be ethical decision making and/or skills and context knowledge. [It] was definitely an area that needed some attention ( Interpreting Agency Manager 4, 5 years’ experience ). Interpreters also stated that the training improved their ability to mediate assessments, work effectively with clinicians, use medical terminology, recognise different dementia presentations, and overcome prior misconceptions. This training makes me understand why they [patient] are so illogical, because their cognitive capability is impaired or something. So, I have to keep that illogical [syntax] in my interpreting ( Mandarin interpreter, 3 years’ experience) . Clinicians were largely unable to comment on changes in interpreter performance following the training rollout. Nonetheless, they emphasised the critical role of interpreters in supporting equitable access to healthcare for multilingual patients. Clinicians highlighted the value of interpreters who can appropriately mediate assessments, accurately convey diagnostic language cues such as pronunciation or word-finding difficulties and comprehension problems and demonstrate a clear understanding of their role in cognitive assessments, including not ‘jumping in’ by answering on behalf of patients. The training sort of tries to sort of talk through their [interpreter’s] sort of role and what they should do… We're asking leading questions because we want to see what answers they [patients] give (Clinician 3: Geriatrician, 2 years’ experience) . Adoption Interpreters reported learning about the training through a range of recruitment channels, including emails and newsletters from industry partners, Google searches for professional development opportunities, social media (e.g., LinkedIn), and direct contact with the research team. Our outreach to hospitals, universities, and private agencies also resulted in them sending direct communications to their interpreters and professional networks about the training. The main facilitators to accessing and completing the training were its ease of access (being online and no cost), offering PD points as an incentive, a straightforward final assessment, and administrative support (including reminders). The main barriers were time constraints, technical issues/lack of computer literacy, and difficulty level of the content for some interpreters. The quizzes - I love them. Yeah. Because it makes me like, go back. And if I did answer one wrong, I go back and I find it. After I read it again, like it sticks in my mind ( Assyrian and Chaldean interpreter, 12 years’ experience ). I'd done half and then sort of forgot about finishing it, got distracted with other things. The reminder was very handy that I have to get back to finishing it. Yes, and I finished it in another deep, long session ( Ukrainian and Russian interpreter, 2 years’ experience ). Initially I think it's not always clear as to how you have to use it [online portal]. [...] If you are using it regularly then it's so easy. But when you use it for the first time, I think it's always an issue ( Hindi, Punjabi and Urdu interpreter, 11 years’ experience ). The questions at the end. [...] Some of them were tricky … It's not very clear cut … it's easy to get confused ( Macedonian interpreter, 45 years’ experience ). Although interpreter managers were not directly involved in delivering or monitoring the training, they estimated that between 1.5% and 33% of their staff had completed it. Similar to interpreters, managers noted that the accrual of PD points as an incentive as well as offering free training, given the low remuneration of interpreters and the prevalence of fee-based training in the sector. Managers also noted the intrinsic motivation among some interpreters to learn and “engage with the profession,” especially those who had studied interpreting in university compared to others, who might see interpreting as “just a job.” Those that have completed the training, I'm pretty sure they've all got enough [PD] points. You know, these are people that are quite engaged with the profession (Interpreting Agency Manager 2, 20 years’ experience) . You will have interpreters who see this as a profession and who've done this in university and a post grad level, while you will also have some interpreters in other new and emerging languages where it's just a job for them. You know, they might be doing it as part of another job. As a casual job few days of the week while they're driving an Uber (Interpreting Agency Manager 4, 5 years’ experience) . Managers identified several barriers to training completion, including interpreters’ prior experience and proficiency in the field, as well as the high prevalence of freelance or casual employment (such interpreters are also known as ‘sessionals’ in Australia). Having a casualised workforce limited workplace communication, leaving many interpreters unaware of peers’ activities and available opportunities to advance their learning. Usually, interpreters are not remunerated for undertaking training. Many interpreters work across multiple agencies as sessionals, making it difficult to mandate training. Interpreting is largely solitary work, making it challenging to monitor the impact of training on individual practice. And I think that with a lot of the sessionals, you know, they will claim they don't have the time for it because of course it's not paid for them to do the training … This worries me quite a lot. I feel that, you know, it's really, really, difficult to engage people that are on a contract casual basis (Interpreting Agency Manager 2, 20 years’ experience). Implementation While most aspects of the training were well received and improved interpreter practice and clinical interactions (see section on Effectiveness), interpreters said that a fast-paced clinical environment made it difficult to implement training recommendations on briefings and debriefings. The job is assigned to the interpreter through the provider. And not all providers brief the interpreter of what they are going into. […] So honestly, it's a surprise for the interpreter […] But with the medical setting? Not really. I haven't really come across a briefing before I go to a medical setting (Arabic interpreter, 1 year of experience) . Sometimes the clinicians themselves, they don't always provide a very detailed briefing (Italian interpreter, 12 years’ experience) . Nevertheless, both interpreters and clinicians recognised the value of briefings and debriefings in preparing for sessions, addressing cultural considerations, and fostering improved working relationships. Interpreters noted that proper briefings enhanced their performance and that debriefings provided opportunities to reflect, learn from mistakes, and strengthen collaboration with clinicians for future sessions. Clinicians similarly acknowledged these benefits but observed that briefings and debriefings did not always occur, were often brief, and varied in detail depending on the clinician and interpreter. If they're [interpreter] very engaged and kind of receptive and reactive, they're the ones that are very good. Some of them kind of just roll their eyes and go, “Oh, I've done this, you know, 1000 times.” And they kind of go off and do their own thing. And you go … “Actually, like I'm kind of leading this, it's not really you” (Clinician 3: Geriatrician, 2 years’ experience) . Experienced interpreters reported that the training did not fundamentally alter their practice but reinforced existing knowledge and skills, thereby increasing their confidence. For interpreters working within a strong therapeutic alliance with clinicians and patients, this reinforcement possibly enhanced the quality of assessments and outcomes. However, clinicians were also concerned that those interpreters who were overconfident could be cavalier and perpetuate poor practice. Additionally, interpreters and managers reported making three adaptations to the training in their practice. The first, was extending the training insights beyond mediating cognitive assessments to interpreting jobs in the broader mental health and aged care settings. It's [training] not only applicable, you know, to dementia. It could be other similar scenarios … especially in the space of mental health … when patients are, some of them are taking lots of medication and then, you know, their mental health is a bit impaired and they can become a bit aggressive or not be fully aware of what they're saying in that moment. So, mainly around how to deal with information that you can't really understand sometimes. Cases like that we have a lot ( Interpreting agency manager 1, 1 year of experience ). The second adaptation was in strengthening interpreter’s roles in their communities as advocates for dementia. Many noted that there was limited knowledge of dementia in ethnically diverse communities with misconceptions and community stigma delaying seeking health and aged care services. Interpreters valued the training for providing them with knowledge that they could use to promote community awareness, so that those caring for a person with dementia can better support their family member and show greater empathy: I had friends complaining about, you know, they no longer wanted to spend time with their mothers because “My mother's gone. She's just, you know, she's not my mother-in-law anymore.” And I said, “No, no, your mother is still there. She's just unwell, you know? And she needs your love and support and understanding” (Vietnamese interpreter, 27 years’ experience). The third adaptation of the training – originally designed to cover spoken languages – was its application by sign language interpreters known as Auslan interpreters in Australia. They described several specific challenges related to signed languages not covered by the training such as differences in establishing trust and rapport, a need to be cognisant of body language and maintain eye contact, how to proceed if the client has not processed the sign correctly, and broader issues around proficiency and acquisition of the sign language and the age at which the client learnt sign language. They suggested including a specific Auslan section, including the code of ethics, and tests and questionnaires which might be more appropriate for use in the Auslan population. There was a little bit that, like, you know, sitting next to the person where we sit opposite, you know, and, and just those subtleties on what what we do... We've got our our own separate Auslan interpreter organization, and we follow our [own] code of ethics (Auslan interpreter, 25 years’ experience). One of the main topics for me that wasn't included in those pre and [debriefing] were how there are severe limitations working in a signed language, interpreting some of the elements of the RUDAS … So, you can't just show someone an instruction in English because Auslan is not English on the hands, it's got its own grammar, it's got its own, you know, syntax (Auslan interpreter, 15 years’ experience) . Maintenance Managers and interpreters noted that population ageing, particularly within ethnically diverse communities, is reshaping the demand for interpreting, with dementia and aged care assessments becoming increasingly common. They suggested that if newer booking systems could prioritise interpreters who had completed the training, it would incentivise further uptake amongst interpreters. They also suggested integrating the training into their own agency’s learning management systems and making the training compulsory. The systems that we work with at the moment are not helpful when we're choosing interpreters that have particular qualifications … However, we're in the process of getting new systems and in these systems, we'll be able to identify if people have done specific training … So, I think that, you know, going forward, interpreters will learn that, you know, there are lots of agencies out there that are saying that if you've done this training, you know, you'll be offered the job first (Interpreting Agency Manager 2, 20 years’ experience). These views were reinforced by clinicians who had not heard about the training before being involved in the study, but who saw the value in knowing which interpreters had done the training as this would give clinicians greater confidence in the interpreter’s skill in this area, and possibly enable them to be more targeted during the briefing. So, if there's, you know, an ability to say, you know, we only want to interpreters that have done this training, I think that'll be really useful and would give the clinicians using these interpreters a lot more faith and trust. […] And [clinicians] having an understanding I suppose, of what training the interpreters have had too is good because then they can, I suppose, possibly save time and be able to explain things in a slightly better and more nuanced way (Clinician 3: Geriatrician, 2 years’ experience). Overall, training was seen to strengthen interpreters’ understanding of the aged care system and healthcare professionals working in this system. As such there was widespread enthusiasm from the sector for the training to continue beyond the lifecycle of the study. Therefore, from mid-March 2025 the training was established to the NAATI portal where it remains freely available to any interpreter in Australia and New Zealand. Discussion As of 30 June 2024, there were 7,481 interpreters with NAATI credentials [ 26 ]. Of this quantum, it was estimated by our industry partners that approximately 6,000 were actively working as interpreters in the health, aged care, and/or community services sector. Thus, by the conclusion of the 12-month implementation study period, 867 or 14.5% of Australia’s active interpreter workforce had completed the training. These are world-first results as a study of this kind has never been completed before. Previous work has highlighted the impact interpreters can have on the accuracy of cognitive assessments [ 11 , 27 , 28 ] and developed training that showed improvements in knowledge and confidence in interpreting skills [ 29 – 33 ]. However, small sample sizes of less than 100 have characterised this work [ 29 , 31 – 33 ] and prior to national implementation, our trial with 126 interpreters had the largest sample to date [ 14 ]. This novel study offers a model for replication in other settings as well as with different disease conditions. Our results were realised through several mechanisms. We engaged with our industry partners from the study’s inception and operationalised their advice in our study design, including codesigning the training with interpreters, clinicians, and ethnically diverse family carers of people with dementia [ 13 ]. During the development and trialling of the training, we sustained our engagement with our partners and the broader sector via two to three annual meetings so that when it came to national implementation in the third and fourth years of the study, we had built coalitions and networks to promote the training [ 34 ]. Scalability and promotion of the training was also achieved by using multiple channels (e.g., industry newsletters, social media) to raise awareness of the training, and keeping it online, no cost, offering PD points as an incentive, streamlining the assessment, and offering timely reminders and technical support. While the sustainability of the training is supported by its free availability on the NAATI website, uptake may decline without ongoing promotion. A ceiling effect may also limit participation, particularly among interpreters who are not intrinsically motivated. This may be partly supported by the finding that those without NAATI credentials were less likely to complete the training, however, there could be other reasons for this. The absence of remuneration for training, additional loading for complex work, and prioritisation of trained interpreters in booking systems underscores structural issues within the interpreting and aged care sectors that extend beyond the scope of a single study to resolve. It is important to address these structural issues as interpreters and managers reported that the training enhanced interpreters’ ability to mediate assessments, collaborate effectively with clinicians, apply medical terminology, recognise diverse dementia presentations, and address prior misconceptions. Professionally, these insights were extended to their performance of mental health and aged care assessments, and privately, to advocating for the greater inclusion of people with dementia in their communities combating the stigma associated with the condition. However, clinicians remained unaware of the training and were equivocal about whether it had any impact on the performance of interpreters they worked with. This finding could be a byproduct of scale – i.e., as more interpreters complete the training, its effects will be more noticeable. It could also be influenced by hierarchy and fit – i.e., there are power imbalances between clinicians and interpreters with the former group not immediately aware of the latter group’s qualifications, and interactions between the pair being relatively transactional [ 19 ]. Broader constraints within the health and aged care system, such as time and resources, may limit the full application of the training in the interpreter’s practice as was the case with briefings and debriefings [ 20 , 22 , 23 , 35 ]. As interpreters reported, briefings were rarely completed, highlighting the need for raising awareness amongst clinicians and the wider dementia assessment team about its importance in a supported and constructive way. Though not touched on in this article (it will be in a later publication), clinicians themselves identified a need to receive training on how to work collaboratively with interpreters, a gap also identified by interpreters and managers in our study. Limitations Due to the casualised nature of the interpreter workforce [ 21 ] and the national scope of the study, in which the training was made available to all interpreters in Australia, agency managers were not involved in its delivery or in monitoring staff uptake. As a result, adoption varied widely across organisations, with only unreliable estimates available from participants. Similarly, NAATI and our industry partners cannot reliably track how many interpreters are currently active in the workforce. Workforce numbers are estimated from the total number of credentialed interpreters; however, many individuals retain their credentials even after retiring, leaving the industry, or moving overseas, which inflates the apparent size of the workforce. Thus, there is a possibility we have underestimated or overestimated the reach of our training. Another limitation is that neither the trial or implementation study observed interpreters while they interpreted a cognitive assessment in ‘real life,’ which means evidence about effectiveness comes from simulations, quiz scores, and interviews. Participants who were clinicians were predominantly from Victoria and overall, participants lived in urban areas. While this corresponds with where most of Australia’s multilingual populations reside [ 36 ], we may have excluded important perspectives from other states and regional and rural areas. Finally, we did not interview ethnically diverse family carers or patients with dementia, who might have had differing views about the quality of the interpreter-mediated communication. Their interactions with interpreters during cognitive assessments are often limited to a single encounter, and a Cochrane review [ 37 ] has highlighted substantial discordance between patient or carer satisfaction and the actual quality of interpreter communication. Moreover, ethnically diverse patients and carers frequently describe this stage of the diagnostic process as highly stressful and burdensome [ 38 , 39 ]. Conclusions Timely dementia diagnosis is influenced by patient, clinician, and health systems factors outside the interpreter’s control. It is overreaching to impute improvements in these outcomes from only interpreter training. But as a composite picture, greater than the sum of its parts, this novel, world-first study provides insights into how to improve the quality of interpreter communication in dementia assessments, ultimately facilitating more timely diagnosis and post-diagnostic care for ethnically diverse people living with dementia. Abbreviations MINDSET: The Improving Interpreting for Dementia Assessments Study NAATI: National Accreditation Authority for Translators and Interpreters PD: Professional development. RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance. YE: Years of Experience Declarations Ethics approval and consent to participate This research study was conducted in adherence with the Declaration of Helsinki. The study was approved by the University of Western Australia (HREC#2021-0477), and the National Aging Research Institute provided governance approval. All participants provided informed consent. Consent for publication Not applicable. Clinical trial number Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests EGG reported receiving grant funding to RMIT University from the Australian National Health and Medical Research Council (NHMRC), administered by the National Ageing Research Institute, to complete interpreter testing and remunerate the assessors who evaluated the performance of the interpreters during the conduct of the study (at the time the grant was awarded, the Australian Institute of Interpreters and Translators [AUSIT] was one of the research partners, and EGG was the president of this professional association); the AUSIT also provided in-kind support for the project. L-FL reported receiving grants from the NHMRC and Medical Research Future Fund, nonfinancial support from Dementia Alliance International and ADNeT, and personal fees from Roche outside the submitted work. No other disclosures were reported. Funding The study was funded by grant APP2005759 from the NHMRC (Profs Brijnath, Low, LoGiudice and Woodward-Kron and; Drs Enticott, Gonzalez, Gilbert, Hlavac, Antoniades, Lin, Hwang, and White) and by the NHMRC Boosting Dementia Leadership Development Fellowship to support work on the MINDSET study (Dr Low) and was supported either financially or in-kind by NAATI, AUSIT, Dementia Australia, New South Wales Health Care Interpreting Service, All Graduates Interpreting and Translation Services, Commonwealth Department of Home Affairs Translation and Interpreting Service, the Commonwealth Department of Health, Disability, and Ageing, Televic, and the Migrant and Refugee Health Partnership (all to Prof Brijnath). The funders had the following roles in the study: The NHMRC, Dementia Australia, Migrant and Refugee Health Partnership, Televic, and Commonwealth Department of Health, Disability, and Ageing: No role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. NAATI, AUSIT, New South Wales Health Care Interpreting Service, All Graduates Interpreting and Translation Services, and Commonwealth Department of Home Affairs Translation and Interpreting Service: Contributed to promoting the training, providing PD points (NAATI), and encouraging interpreters and managers to participate in interviews. These partners had no role in the analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Authors' contributions The concept and design of the study were developed by Brijnath, Enticott, Gilbert, Gonzalez, Low, LoGiudice, Woodward-Kron, Antoniades, Hwang, and White. Data acquisition, analysis, and interpretation were undertaken by Brijnath, Clarke, Markusevska, and Cavuoto. The manuscript was drafted by Brijnath and Cavuoto, and critically reviewed for important intellectual content by Clarke, Markusevska, Enticott, Gilbert, Gonzalez, Hlavac, Low, LoGiudice, Antoniades, Lin, White, and Hwang. Statistical analyses were conducted by Markusevska and Cavuoto. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Ciobanu RO. Ageing in diverse societies. In: Charest É, Kuptsch C, editors. The future of diversity. Geneva: International Labour Organization; 2021. p. 135-49. Wilkinson L. A demographic overview of ethnic diversity in Canada. Immigration, racial and ethnic studies in 150 years of Canada: Brill; 2018. p. 103-28. Australian Bureau of Statistics. Cultural diversity in Australia, 2021: Australian Government; 2022. https://www.abs.gov.au/ausstats/ [email protected] /Lookup/by%20Subject/2071.0%7E2016%7EMain%20Features%7ECultural%20Diversity%20Article%7E60. Accessed 14 October 2025. Temple J, Wilson T, Brijnath B, Radford K, LoGiudice D, Utomo A, et al. The role of demographic change in explaining the growth of Australia's older migrant population living with dementia, 2016–2051. Australian and New Zealand Journal of Public Health. 2022;46(5):661-7. Goth US, Strøm BS. Language disintegration: communication ability in elderly immigrants with dementia. Lancet Public Health. 2018;3(12):e563. Gove D, Nielsen TR, Smits C, Plejert C, Rauf MA, Parveen S, et al. The challenges of achieving timely diagnosis and culturally appropriate care of people with dementia from minority ethnic groups in Europe. Int J Geriatr Psychiatry. 2021;36(12):1823-8. Haralambous B, Tinney J, LoGiudice D, Lee SM, Lin X. Interpreter-mediated cognitive assessments: who wins and who loses? Clin Gerontol. 2018;41(3):227-36. NHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People. Clinical practice guidelines and principles of care for people with dementia. Sydney: National Health and Medical Research Council; 2016. Kasten MJ, Berman AC, Ebright AB, Mitchell JD, Quirindongo-Cedeno O. Interpreters in health care: a concise review for clinicians. Am J Med. 2020;133(4):424-8.e2. Plejert C. Challenges and remedies for interpreter-mediated dementia assessments. In: Gavioli L, Wadensjö C, editors. The Routledge handbook of public service interpreting. First edition. New York, NY: Routledge; 2023. Torkpoor R, Fioretos I, Essén B, Londos E. "I know hyena. do you know hyena?" Challenges in interpreter-mediated dementia assessment, focusing on the role of the interpreter. J Cross Cult Gerontol. 2022;37(1):45-67. Gilbert AS, Croy S, Hwang K, LoGiudice D, Haralambous B. Video remote interpreting for home-based cognitive assessments. Interpreting. 2022;24(1):84-110. Gilbert AS, Antoniades J, Hwang K, Gonzalez E, Hlavac J, Enticott J, et al. The MINDSET study: co-designing training for interpreters in dementia and cognitive assessments. Dementia. 2023;22(7):1604-25. Brijnath B, Markusevska S, Enticott J, Sethi P, Gilbert AS, Gonzalez E, et al. Interpreter communication quality in cognitive assessments for dementia: the mindset randomized clinical trial. JAMA Network Open. 2025;8(2):e2458069-e. Glasgow RE, Estabrooks PE. Pragmatic applications of RE-AIM for health care initiatives in community and clinical settings. Prev Chronic Dis. 2018;15:E02. Holtrop JS, Rabin BA, Glasgow RE. Qualitative approaches to use of the RE-AIM framework: rationale and methods. BMC Health Serv Res. 2018;18(1):177. Brijnath B, Gonzalez E, Hlavac J, Enticott J, Woodward-Kron R, LoGiudice D, et al. The impact of training on communication quality during interpreter-mediated cognitive assessments: Study protocol for a randomized controlled trial. A&D: TRCI. 2022;8(1):e12349. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795. Eser O. Challenges facing the community interpreting industry. Understanding community interpreting services: diversity and access in Australia and beyond. Cham: Springer International Publishing; 2020. p. 43-78. Hlavac J. The development of community translation and interpreting in Australia: a critical overview. Translating and Interpreting in Australia and New Zealand. 2021:65-85. Beinchet A, Taibi M. Community translation and interpreting under neoliberal agendas: the cases of Australia and Canada. In: Jalalian Daghigh A, Shuttleworth M, editors. Translation and Neoliberalism. Cham: Springer Nature Switzerland; 2024. p. 99-118. Lai M, Costello S. Professional interpreters and vicarious trauma: an Australian perspective. Qual Hlth Res. 2021;31(1):70-85. Crezee I. Teaching interpreters about self-care. IJIE. 2015;7(1):7. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods.2017;16(1):1609406917733847. National Accreditation Authority for Translators and Interpreters. NAATI Annual Report 2023-2024. Canberra: NAATI; 2024. Majlesi AR, Plejert C. Embodiment in tests of cognitive functioning: a study of an interpreter-mediated dementia evaluation. Dementia. 2018;17(2):138-63. Plejert C, Lindholm C, Schrauf RW. Multilingual interaction and dementia: multilingual matters. Bristol; 2017. Ono N, Kiuchi T, Ishikawa H. Development and pilot testing of a novel education method for training medical interpreters. Patient Educ Couns 2013;93(3):604-11. Fioretos I, Torkpoor R. Inga om men eller varför: Att främja säker och jämlik kognitiv utredning genom tolk. : Kunskapscentrum demenssjukdomar, Migrationsskolan. 2019. Zhang CX, Crawford E, Marshall J, Bernard A, Walker-Smith K. Developing interprofessional collaboration between clinicians, interpreters, and translators in healthcare settings: outcomes from face-to-face training. J Interprof Care. 2021;35(4):521-31. Carlson ES, Barriga TM, Lobo D, Garcia G, Sanchez D, Fitz M. Overcoming the language barrier: a novel curriculum for training medical students as volunteer medical interpreters. BMC Med Edu. 2022;22(1):27. Abdulkadir LS, Sodemann M, Gudex C, Möller S, Nielsen DS. The impact of a health introduction course for medical interpreters in the healthcare sector. Nord. J. Nurs. Res. 2020;41(2):109-16. WHO. Practical guidance for scaling up health service innovations. Geneva; 2009. Nielsen TR, Franzen S, Watermeyer T, Jiang J, Calia C, Kjærgaard D, et al. Interpreter-mediated neuropsychological assessment: Clinical considerations and recommendations from the European Consortium on Cross-Cultural Neuropsychology (ECCroN). Clinical Neuropsychologist. 2024;38(8):1775-805. Wang S, Sun QC, Martin C, Cai W, Liu Y, Duckham M, et al. Tracking the settlement patterns of culturally and linguistically diverse (CALD) populations in Australia: a census-based study from 2001 to 2021. Cities. 2023;141:104482. Tsuruta H, Karim D, Sawada T, Mori R. Trained medical interpreters in a face‐to‐face clinical setting for patients with low proficiency in the local language. Cochrane Database Syst Rev. 2016(5). LoGiudice D, Hassett A, Cook R, Flicker L, Ames D. Equity of access to a memory clinic in Melbourne? Non-English speaking background attenders are more severely demented and have increased rates of psychiatric disorders. Int J Geriatr Psychiatry. 2001;16(3):327-34. NHMRC National Institute for Dementia Research (NNIDR). Culturally and linguistically diverse (CALD) dementia research action plan: Full report. Canberra: NNIDR; 2020. Additional Declarations Competing interest reported. EGG reported receiving grant funding to RMIT University from the Australian National Health and Medical Research Council (NHMRC), administered by the National Ageing Research Institute, to complete interpreter testing and remunerate the assessors who evaluated the performance of the interpreters during the conduct of the study (at the time the grant was awarded, the Australian Institute of Interpreters and Translators [AUSIT] was one of the research partners, and EGG was the president of this professional association); the AUSIT also provided in-kind support for the project. L-FL reported receiving grants from the NHMRC and Medical Research Future Fund, nonfinancial support from Dementia Alliance International and ADNeT, and personal fees from Roche outside the submitted work. No other disclosures were reported. Supplementary Files Additionalfile1.docx Additional file 1: Multiple choice assessment quiz for training Additionalfile2.docx Additional file 2: Interview schedules for interpreter, interpreter managers, and clinicians. Additionalfile3.docx Additional file 3: STARi checklist Cite Share Download PDF Status: Published Journal Publication published 05 Mar, 2026 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 07 Jan, 2026 Reviews received at journal 07 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers agreed at journal 02 Jan, 2026 Reviews received at journal 23 Dec, 2025 Reviewers agreed at journal 19 Dec, 2025 Reviewers invited by journal 17 Dec, 2025 Editor assigned by journal 17 Dec, 2025 Editor invited by journal 09 Dec, 2025 Submission checks completed at journal 07 Dec, 2025 First submitted to journal 07 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:09:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1248131,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8208390/v1/35b79cfc-0640-4486-aa8f-ea1ec6e946ff.pdf"},{"id":98640276,"identity":"10c920a0-3d9b-4fcb-ad5f-e665a1930b9b","added_by":"auto","created_at":"2025-12-19 18:18:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27474,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1: Multiple choice assessment quiz for training\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8208390/v1/2a3059e33e736bf2f5af4645.docx"},{"id":98776016,"identity":"b90b1c0b-3f62-495a-ac62-9247683f09f8","added_by":"auto","created_at":"2025-12-22 12:21:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":27141,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2: Interview schedules for interpreter, interpreter managers, and clinicians.\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8208390/v1/4b2f139cd1cbe1cf946fb194.docx"},{"id":98640281,"identity":"f1a85f81-6a4f-42ea-88da-7474236ac4e5","added_by":"auto","created_at":"2025-12-19 18:18:44","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":81350,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 3: STARi checklist\u003c/p\u003e","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8208390/v1/0002d2fd823118fc976d182d.docx"}],"financialInterests":"Competing interest reported. EGG reported receiving grant funding to RMIT University from the Australian National Health and Medical Research Council (NHMRC), administered by the National Ageing Research Institute, to complete interpreter testing and remunerate the assessors who evaluated the performance of the interpreters during the conduct of the study (at the time the grant was awarded, the Australian Institute of Interpreters and Translators [AUSIT] was one of the research partners, and EGG was the president of this professional association); the AUSIT also provided in-kind support for the project. L-FL reported receiving grants from the NHMRC and Medical Research Future Fund, nonfinancial support from Dementia Alliance International and ADNeT, and personal fees from Roche outside the submitted work. No other disclosures were reported.","formattedTitle":"Implementing interpreter training for dementia assessments at national scale using the RE-AIM framework: A mixed-methods evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAustralia, like other high-income countries such as those in Europe [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] or Canada [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], has an increasingly ethnically diverse and ageing population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These demographic shifts are contributing to a rise in age-related conditions, including dementia, among ethnically diverse older people. By 2056, dementia prevalence will increase by 67% among overseas-born Australians compared with 58% among those born in Australia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo meet the needs of this growing cohort, health and aged care services must prioritise culturally appropriate care, including access to professional interpreter support. This is particularly important during cognitive assessments for dementia, as aphasia often first appears in non-primary languages before affecting primary languages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring cognitive assessments, interpreters play a vital role in mediating both verbal and non-verbal communication between patients and clinicians, facilitating timely and accurate diagnosis, access to treatment, and post-diagnostic supports [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Without specialised training, however, interpreter involvement can lead to reduced satisfaction among patients and clinicians, increased conflict, and diagnostic delays [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Interpreting cognitive assessments requires a very high level of verbal and linguistic accuracy, with inaccurate or missed speech potentially compromising the assessment result [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Given that cognitive assessments require a high degree of linguistic precision, even small errors or omissions in interpreting can compromise assessment outcomes. In our previous work, interpreters reported that people with dementia represented a growing proportion of their clientele, and that they sought specialist training in mediating cognitive assessments for dementia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecognising this need, The Improving Interpreting for Dementia Assessments (MINDSET) study codesigned [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and trialled [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] a specialized online training program on dementia and cognitive assessments for interpreters. The trial engaged 126 interpreters across six languages commonly spoken by older Australians (Arabic, Cantonese, Greek, Italian, Mandarin, and Vietnamese). Findings from this single-blind, parallel-group randomized clinical trial showed significant improvements in the quality of interpreter communication at 3 months among those who completed at least 70% of the training [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuilding on these results, the training was subsequently scaled for national implementation, making it available to all interpreters in Australia. The implementation was guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], a widely used framework in implementation research that evaluates not only effectiveness but also real-world translation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. RE-AIM enables systematic assessment of who benefits from an intervention, how it is adopted across settings, the consistency of its delivery, and its sustainability over time [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This comprehensive perspective provided a robust foundation for translating the outcomes of the MINDSET trial into routine practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The aim of this article is to report on the implementation of the MINDSET training, focusing on its reach, barriers and facilitators to adoption and implementation, real-world effectiveness in supporting interpreter mediated cognitive assessments for dementia, and potential for long-term maintenance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eA mixed-methods design was applied. Quantitative monitoring captured the training\u0026rsquo;s reach, uptake, and completion rates while qualitative interviews explored the experiences of interpreters who completed the training, their agency managers, and clinicians working with interpreters during cognitive assessments. The protocol is published [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and the Standards for Reporting Implementation Studies (StaRI) reporting guideline was followed [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Ethical approval was obtained from the University of Western Australia Human Research Ethics Committee, with governance approval provided by the National Ageing Research Institute. Participants all provided informed consent prior to completing the training and interviews.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eContext\u003c/h3\u003e\n\u003cp\u003eInterpreters represent a largely invisible and understudied workforce. In Australia, they often work under challenging conditions characterised by insecure employment, variable pay rates, and high emotional demands [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Most interpreters are engaged on a casual or per-assignment basis across multiple agencies, with limited access to stable income, paid leave, or professional development opportunities [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Within health and social service settings, interpreters also face significant pressures, including strict time constraints, exposure to sensitive or traumatic content, and the need to rapidly adapt to different languages and cultural contexts [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These working conditions can contribute to stress, burnout, and workforce shortages, underscoring the importance of providing greater support, recognition, and professional development opportunities for interpreters [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eTargeted ‘sites’ and populations\u003c/h3\u003e\n\u003cp\u003eGiven the casualised nature of the Australian interpreter workforce, this study was community-based and conducted online across Australia between 24 November 2023 and 12 December 2024. The evaluation included interpreters, their managers, and clinicians.\u003c/p\u003e \u003cp\u003eInterpreters, the target of the training intervention, were eligible if they: (i) interpreted in any spoken or signed language, ii) lived in Australia, and iii) had internet access. No restrictions were placed on interpreting qualifications or experience, and students were eligible to participate.\u003c/p\u003e \u003cp\u003eInterpreter agency managers and clinicians were the focus of the implementation evaluation. Managers were eligible if they (i) worked in leadership roles at public and private organizations, and (ii) had oversight of interpreter professional development. Clinicians were eligible if they worked (i) in health settings offering diagnostic dementia services (e.g., memory clinics, hospitals), and ii) with interpreters during cognitive assessments for dementia at least once a month.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe four-hour training was co-designed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and incorporated written materials and instructional videos alongside links to key external readings. It addressed five core domains: dementia knowledge, cross-cultural communication, briefings and debriefings, interpreting skills, and interpreting ethics [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eImplementation strategies\u003c/h3\u003e\n\u003cp\u003eTo promote the training, it was freely available, online, and self-paced. Interpreters could claim up to 20 professional development (PD) points upon successful completion that could be counted towards the renewal of their credentials for three years from the National Accreditation Authority for Translators and Interpreters (NAATI), Australia\u0026rsquo;s national standards and certifying body for translators and interpreters. It was comprehensively marketed over 12 months through two launches (online and in-person at a national interpreter conference); a social media campaign with 43 posts shared across LinkedIn, Facebook, and X; and notifications about the training in industry newsletters, electronic mailing lists, and e-bulletins. We also asked our industry partners \u0026ndash; i.e., three interpreter agencies (one federal, one state, one private company), two advocacy groups, a technology partner, and NAATI \u0026ndash; to directly contact interpreters registered with them to alert them about the training. Hospital interpreting services, university and vocational course coordinators, and private interpreter agencies were also contacted to request they promote the training to their interpreters.\u003c/p\u003e \u003cp\u003eTo facilitate enrolment in the training, interpreters expressed their interest via a quick-response code linked to a Microsoft form that included eligibility screening questions, a consent form, and basic demographic information. They were then directed to an online link to register for and access the online training. This was regularly monitored by the research team who provided technical support to anyone who could not register or had not registered following completion of the form. Mass emails were used to remind participants who had expressed interest to enrol in the training.\u003c/p\u003e \u003cp\u003eTo encourage completion of the training, weekly reminder emails were sent to enrolled participants. A 1-month time limit was advertised to enhance completion; however, interpreters were always given an extension if requested. The original trial assessment \u0026ndash; a 30\u0026ndash;40-minute video simulation of a cognitive assessment graded by assessors who are also NAATI test examiners and educators familiarised with the NAATI testing rubrics \u0026ndash; was removed from this iteration of the training due to its cost, time demands, and limited availability across languages. Instead, a single end-of-training quiz was introduced (Additional file 1), allowing automatic scoring, immediate feedback, unlimited retakes, and the option to download a completion certificate.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e described how RE-AIM [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] was operationalised in our implementation outcomes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRE-AIM implementation outcome measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE-AIM dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow it was assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType of data (qualitative/quantitative)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRates and representativeness of interpreters who enrolled and completed the training compared to those who did not.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Multiple-choice assessment quiz at training completion\u003c/p\u003e \u003cp\u003e\u0026bull; Qualitative interviews with interpreters, managers, and clinicians.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative\u003c/p\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvaluated through interpreter and manager interviews, focusing on barriers and enablers to adoption of the training.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Rate of completion and time spent on the training.\u003c/p\u003e \u003cp\u003e\u0026bull; Interviews on the perceived value, quality, and impact of the training.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative\u003c/p\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintenance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescribed through collaborations built to promote the training and sustain its availability through industry partnerships beyond the lifecycle of the MINDSET project.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedures\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted online via Microsoft Teams by NC, SM, and MC. Questions focused on understanding if the training was perceived to improve interpreter communication, impact practice, and clinician satisfaction (see Additional file 2). Interpreters and clinicians were remunerated for their time at their average hourly professional rate.\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eWe aimed to enrol 2,405 interpreters in the training, approximately 70% of NAATI accredited interpreters in the above-mentioned six languages (Arabic, Cantonese, Greek, Italian, Mandarin, and Vietnamese n\u0026thinsp;=\u0026thinsp;3,400).\u003c/p\u003e \u003cp\u003e Once 30% of the sample had been screened (n\u0026thinsp;=\u0026thinsp;722), we invited 140 interpreters who had enrolled in the training to participate in an interview. Purposive sampling was used to ensure participants were diversified by sex, language, location (state, urbanicity), and NAATI credentialing. Concurrently, we also invited 10 interpreter agency managers to participate in an interview.\u003c/p\u003e \u003cp\u003eOnce 50% of the sample had been screened (n\u0026thinsp;=\u0026thinsp;1,203), clinicians working in catchment areas with high ethnic diversity were invited to be interviewed using a combination of purposive and snowball sampling. Again, we sought to diversify our sample by profession (e.g., geriatrician, psychiatrist, nurse, allied health) and state.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eQuantitative data were descriptively analysed in SPSS Version 29.0.1.0.\u003c/p\u003e \u003cp\u003eInterviews (up to one hour in length) were audio recorded and transcribed verbatim by an external transcription service, with identifying data removed. Using the framework method [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], two researchers (NC and BB) independently coded two interviews, then met to discuss their codes from which a working schema was developed through consensus. Using this scheme, NC and MC replicated the process on two additional transcripts, further refining the schema and developing a draft analytical framework. The cycle was repeated twice more involving NC, SM, and BB before the analytical framework was finalised. NC then coded all transcripts in NVivo version 12.6.0.959. Data were initially analysed inductively and then text and code were mapped against the predetermined RE-AIM domains, specifically effectiveness, adoption, and implementation.\u003c/p\u003e \u003cp\u003eIn this way, a multidisciplinary team ensured agreement on the themes and coding of text. Any differences between researchers were negotiated and if necessary, regrouped and recoded until consensus was reached. Such steps ensure consistency [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Their interpretations and summaries were also continuously presented to the wider team for verification and further refinement. We adopted key strategies to enhance study rigor. Dependability and the ability to replicate this study was enhanced using an audit trail, a clear analytic process and peer debriefing [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Credibility and confirmability was achieved through reflexivity, transparency in thorough team discussion, and the use of verbatim quotes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Thus, data trustworthiness was established through triangulation, audit trails, and consensus validation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eCharacteristics of participants\u003c/h2\u003e\n \u003cp\u003eOverall, there were 2,424 expressions of interest to complete the training via the online form, of which 420 did not consent to further participation in the study, 369 did not live in Australia, 90 were not an interpreter, and 158 had already participated in the MINDSET trial. This left 1,387 eligible participants, most of whom were women (1,046, 75.4%), with a mean age of 49.5 (\u0026plusmn;\u0026thinsp;13.8), and from New South Wales (482, 34.8%) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Eligible participants worked in 103 languages, with Mandarin (17.6%), Arabic (11.4%), and Auslan (8.3%) being the most common.\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics for interpreters who registered for the MINDSET training\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParticipant characteristics (n\u0026thinsp;=\u0026thinsp;1387)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1046 (75.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e327 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.5 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew South Wales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e482 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVictoria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e428 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQueensland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e171 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWestern Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTasmania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorthern Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralian Capital Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNAATI credential status, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertified Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e524 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertified Provisional Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e552 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecognised Practicing Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecialised Health Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e225 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertificate III-IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma or Advanced Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e245 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e392 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Honours Degree, Graduate Diploma or Graduate Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate Degree (Masters or Doctoral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e524 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education in interpreting, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e368 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTAFE Short Course\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma or Advanced Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e481 (34.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Honours Degree, Graduate Diploma or Graduate Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate Degree (Masters or Doctoral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e227 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e[INSERT Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003cp\u003eAlongside, we interviewed 24 interpreters who worked in established (e.g., Greek, Italian) and emerging languages (e.g., Oromo, Ukrainian), six interpreter managers, and 16 clinicians including geriatricians (n\u0026thinsp;=\u0026thinsp;6), clinical neuropsychologists (n\u0026thinsp;=\u0026thinsp;4), social workers (n\u0026thinsp;=\u0026thinsp;3), physiotherapist (n\u0026thinsp;=\u0026thinsp;1), psychiatrist (n\u0026thinsp;=\u0026thinsp;1) and occupational therapist (n\u0026thinsp;=\u0026thinsp;1) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Most participants were based in urban areas, from Victoria or New South Wales, the two most populous and multilingual states in Australia.\u003c/p\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eInterview participant characteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterpreters\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterpreter managers\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eClinicians\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex female n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrban-based\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(83%)^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (100%)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eACT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNSW\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eQLD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTAS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVIC\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eWA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1(4%)\u003c/p\u003e\n \u003cp\u003e6(25%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1(4%)\u003c/p\u003e\n \u003cp\u003e4(17%)\u003c/p\u003e\n \u003cp\u003e2(8%)\u003c/p\u003e\n \u003cp\u003e7(29%)\u003c/p\u003e\n \u003cp\u003e3(13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1(17%)\u003c/p\u003e\n \u003cp\u003e1(17%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e4(67%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2(13%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1(6%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e13(81%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of experience in role (Median)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e^one manager reported working in an outer-regional setting; * one clinician reported working in both an urban and an inner-regional setting.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e[INSERT Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003eReach\u003c/h2\u003e\n \u003cp\u003eOf 1,387 eligible participants, 1,185 enrolled in the training, and 867 completed it (defined as finishing\u0026thinsp;\u0026gt;\u0026thinsp;70% of the training including the quiz; 857 completed 100% of the training). 301 (25.4%) completed\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;25% of the training, 15 (1.3%) 26%-50%, and 2 (0.2%) 51%-70%. For those who completed the training, the median time taken to complete the training was just over one week, although for some participants completion occurred over several months (median\u0026thinsp;=\u0026thinsp;7.81 days, range\u0026thinsp;\u0026lt;\u0026thinsp;1-321 days). Those who completed the training were more likely to be female (\u0026chi;\u003csup\u003e2\u003c/sup\u003e[1, n\u0026thinsp;=\u0026thinsp;1091]\u0026thinsp;=\u0026thinsp;4.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.043); and were older (\u003cem\u003et\u003c/em\u003e(1098)=-3.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001). Significant differences in NAATI credential status were observed between those who completed the training and those who did not (\u0026chi;\u003csup\u003e2\u003c/sup\u003e[3, n\u0026thinsp;=\u0026thinsp;1088]\u0026thinsp;=\u0026thinsp;9.97, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.019), examination of standardised residuals indicated this was driven by those with no NAATI credentials not completing the training. In contrast, there were significant differences in highest level of education between those who did and did not complete the training, however, examination of standardised residuals indicated a diffuse pattern with results not driven by any particular categories (\u0026chi;\u003csup\u003e2\u003c/sup\u003e[3, n\u0026thinsp;=\u0026thinsp;1095]\u0026thinsp;=\u0026thinsp;8.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.042). There were no significant differences in state of residence between those who completed the training and those who did not (\u0026chi;\u003csup\u003e2\u003c/sup\u003e[7, n\u0026thinsp;=\u0026thinsp;1094]\u0026thinsp;=\u0026thinsp;12.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.099). Differences in rates and representativeness of interpreters who enrolled and completed the training compared to those who did not is described in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eCharacteristics of interpreters who enrolled and did and did not complete the training.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eParticipant characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraining completers\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraining non-completers\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing demographic data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender, n (%)^\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e623 (71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e218 (68.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e168 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.19 (13.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.22 (13.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNew South Wales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e279 (35.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (32.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVictoria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e224 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116 (38.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQueensland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWestern Australia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTasmania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorthern Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralian Capital Territory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNAATI credential status, n (%)\u003c/strong\u003e ^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertified Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e311 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertified Provisional Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e308 (38.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecognised Practicing Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecialised Health Interpreter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e122 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education, n (%)\u003c/strong\u003e ^\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e.042\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCertificate III-IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiploma or Advanced Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e133 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e237 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor Honours Degree, Graduate Diploma or Graduate Certificate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostgraduate Degree (Masters or Doctoral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e299 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTop 5 interpreting languages, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMandarin, 138 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMandarin, 43 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArabic, 85 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAuslan, 37 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAuslan, 71 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArabic, 30 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVietnamese, 52 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVietnamese, 24 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpanish, 47 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpanish, 23 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e^Due to small sample sizes in the non-binary and prefer not to say categories, statistical testing on gender was only performed on males/females. Due to small sample sizes in NAATI credential status categories, the specialised health interpreter category was combined with the certified interpreter category, and the \u0026lsquo;other\u0026rsquo; category was removed from the analysis. Due to small sample sizes, high school graduate was combined with certificate III-IV, Bachelor Degree was combined with Bachelor Honours Degree, Graduate Diploma or Graduate Certificate degree and \u0026lsquo;other\u0026rsquo; was not included in the statistical analysis. Differences in languages were not statistically analysed due to the large number of categories, and small sample sizes for each. Instead, the top 5 languages are presented for descriptive purposes only.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e[INSERT Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003eEffectiveness\u003c/h2\u003e\n \u003cp\u003eResults of the assessment quiz on completion of the training indicated a high overall score, with an average of 25.06 out of a possible 29, and a high overall pass rate (99% of participants), based on all attempts at the quiz. As participants had unlimited attempts to re-take the quiz, the average score and pass rate were higher when considering their highest attempt, with an overall average of 25.40, and pass rate of 99.8%, respectively.\u003c/p\u003e\n \u003cp\u003eApproximately half of the interviewed interpreters had undertaken a cognitive assessment since completing the training, and most reported feeling well prepared for these sessions.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAfter the training I had [on] two occasions interpreted for the dementia patient and also family members. Yes, and some of the knowledge did help. [...] I know how the assessment works and how to communicate to a dementia patient and try to like make my interpreting as accurate as possible by like, sometimes parroting the way they were talking. So that we can make an accurate diagnosis \u003cem\u003e(Mandarin interpreter, 19 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eInterpreters said they valued the structured learning format, which contrasted with the ad hoc knowledge typically acquired on the job, and noted it was especially beneficial for those without a health background. Managers reinforced that the training helped interpreters appreciate the complexity of the area, and that it was a sensitive topic that required attention. Several interpreters mentioned that the training would be especially important for new interpreters to provide foundational knowledge, and some even suggested it should be a requirement to get accreditation.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIt [training] has a lot of benefits. Personally, if I begin from myself, I don\u0026apos;t have that information at all. The science, what can I do, so knowing those all information, it helps me to understand [\u0026hellip;] So if you don\u0026apos;t know what cognitive assessment, sometimes we don\u0026apos;t know during interpreting, sometimes I don\u0026apos;t know the topic, so I have to ask the doctor what does it mean? (\u003cem\u003eAmharic and Oromo interpreter, years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003cp\u003eSome of the things were a bit basic for more advanced interpreters, I think people have been doing it for a long time. But I think it\u0026apos;s particularly useful for the ones that are just starting (\u003cem\u003eInterpreting Agency Manager 1, 1 year of experience)\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003eDementia, voluntary assisted dying. These are all very difficult settings for interpreters, whether it be ethical decision making and/or skills and context knowledge. [It] was definitely an area that needed some attention (\u003cem\u003eInterpreting Agency Manager 4, 5 years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eInterpreters also stated that the training improved their ability to mediate assessments, work effectively with clinicians, use medical terminology, recognise different dementia presentations, and overcome prior misconceptions.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThis training makes me understand why they [patient] are so illogical, because their cognitive capability is impaired or something. So, I have to keep that illogical [syntax] in my interpreting (\u003cem\u003eMandarin interpreter, 3 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eClinicians were largely unable to comment on changes in interpreter performance following the training rollout. Nonetheless, they emphasised the critical role of interpreters in supporting equitable access to healthcare for multilingual patients. Clinicians highlighted the value of interpreters who can appropriately mediate assessments, accurately convey diagnostic language cues such as pronunciation or word-finding difficulties and comprehension problems and demonstrate a clear understanding of their role in cognitive assessments, including not \u0026lsquo;jumping in\u0026rsquo; by answering on behalf of patients.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe training sort of tries to sort of talk through their [interpreter\u0026rsquo;s] sort of role and what they should do\u0026hellip; We\u0026apos;re asking leading questions because we want to see what answers they [patients] give \u003cem\u003e(Clinician 3: Geriatrician, 2 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eAdoption\u003c/h2\u003e\n \u003cp\u003eInterpreters reported learning about the training through a range of recruitment channels, including emails and newsletters from industry partners, Google searches for professional development opportunities, social media (e.g., LinkedIn), and direct contact with the research team. Our outreach to hospitals, universities, and private agencies also resulted in them sending direct communications to their interpreters and professional networks about the training.\u003c/p\u003e\n \u003cp\u003eThe main facilitators to accessing and completing the training were its ease of access (being online and no cost), offering PD points as an incentive, a straightforward final assessment, and administrative support (including reminders). The main barriers were time constraints, technical issues/lack of computer literacy, and difficulty level of the content for some interpreters.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe quizzes - I love them. Yeah. Because it makes me like, go back. And if I did answer one wrong, I go back and I find it. After I read it again, like it sticks in my mind (\u003cem\u003eAssyrian and Chaldean interpreter, 12 years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003cp\u003eI\u0026apos;d done half and then sort of forgot about finishing it, got distracted with other things. The reminder was very handy that I have to get back to finishing it. Yes, and I finished it in another deep, long session (\u003cem\u003eUkrainian and Russian interpreter, 2 years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003cp\u003eInitially I think it\u0026apos;s not always clear as to how you have to use it [online portal]. [...] If you are using it regularly then it\u0026apos;s so easy. But when you use it for the first time, I think it\u0026apos;s always an issue (\u003cem\u003eHindi, Punjabi and Urdu interpreter, 11 years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003cp\u003eThe questions at the end. [...] Some of them were tricky \u0026hellip; It\u0026apos;s not very clear cut \u0026hellip; it\u0026apos;s easy to get confused (\u003cem\u003eMacedonian interpreter, 45 years\u0026rsquo; experience\u003c/em\u003e).\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eAlthough interpreter managers were not directly involved in delivering or monitoring the training, they estimated that between 1.5% and 33% of their staff had completed it. Similar to interpreters, managers noted that the accrual of PD points as an incentive as well as offering free training, given the low remuneration of interpreters and the prevalence of fee-based training in the sector. Managers also noted the intrinsic motivation among some interpreters to learn and \u0026ldquo;engage with the profession,\u0026rdquo; especially those who had studied interpreting in university compared to others, who might see interpreting as \u0026ldquo;just a job.\u0026rdquo;\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThose that have completed the training, I\u0026apos;m pretty sure they\u0026apos;ve all got enough [PD] points. You know, these are people that are quite engaged with the profession \u003cem\u003e(Interpreting Agency Manager 2, 20 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003eYou will have interpreters who see this as a profession and who\u0026apos;ve done this in university and a post grad level, while you will also have some interpreters in other new and emerging languages where it\u0026apos;s just a job for them. You know, they might be doing it as part of another job. As a casual job few days of the week while they\u0026apos;re driving an Uber \u003cem\u003e(Interpreting Agency Manager 4, 5 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eManagers identified several barriers to training completion, including interpreters\u0026rsquo; prior experience and proficiency in the field, as well as the high prevalence of freelance or casual employment (such interpreters are also known as \u0026lsquo;sessionals\u0026rsquo; in Australia). Having a casualised workforce limited workplace communication, leaving many interpreters unaware of peers\u0026rsquo; activities and available opportunities to advance their learning. Usually, interpreters are not remunerated for undertaking training. Many interpreters work across multiple agencies as sessionals, making it difficult to mandate training. Interpreting is largely solitary work, making it challenging to monitor the impact of training on individual practice.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eAnd I think that with a lot of the sessionals, you know, they will claim they don\u0026apos;t have the time for it because of course it\u0026apos;s not paid for them to do the training \u0026hellip; This worries me quite a lot. I feel that, you know, it\u0026apos;s really, really, difficult to engage people that are on a contract casual basis \u003cem\u003e(Interpreting Agency Manager 2, 20 years\u0026rsquo; experience).\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eImplementation\u003c/h2\u003e\n \u003cp\u003eWhile most aspects of the training were well received and improved interpreter practice and clinical interactions (see section on Effectiveness), interpreters said that a fast-paced clinical environment made it difficult to implement training recommendations on briefings and debriefings.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe job is assigned to the interpreter through the provider. And not all providers brief the interpreter of what they are going into. [\u0026hellip;] So honestly, it\u0026apos;s a surprise for the interpreter [\u0026hellip;] But with the medical setting? Not really. I haven\u0026apos;t really come across a briefing before I go to a medical setting \u003cem\u003e(Arabic interpreter, 1 year of experience)\u003c/em\u003e.\u003c/p\u003e\n \u003cp\u003eSometimes the clinicians themselves, they don\u0026apos;t always provide a very detailed briefing \u003cem\u003e(Italian interpreter, 12 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eNevertheless, both interpreters and clinicians recognised the value of briefings and debriefings in preparing for sessions, addressing cultural considerations, and fostering improved working relationships. Interpreters noted that proper briefings enhanced their performance and that debriefings provided opportunities to reflect, learn from mistakes, and strengthen collaboration with clinicians for future sessions. Clinicians similarly acknowledged these benefits but observed that briefings and debriefings did not always occur, were often brief, and varied in detail depending on the clinician and interpreter.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIf they\u0026apos;re [interpreter] very engaged and kind of receptive and reactive, they\u0026apos;re the ones that are very good. Some of them kind of just roll their eyes and go, \u0026ldquo;Oh, I\u0026apos;ve done this, you know, 1000 times.\u0026rdquo; And they kind of go off and do their own thing. And you go \u0026hellip; \u0026ldquo;Actually, like I\u0026apos;m kind of leading this, it\u0026apos;s not really you\u0026rdquo; \u003cem\u003e(Clinician 3: Geriatrician, 2 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eExperienced interpreters reported that the training did not fundamentally alter their practice but reinforced existing knowledge and skills, thereby increasing their confidence. For interpreters working within a strong therapeutic alliance with clinicians and patients, this reinforcement possibly enhanced the quality of assessments and outcomes. However, clinicians were also concerned that those interpreters who were overconfident could be cavalier and perpetuate poor practice.\u003c/p\u003e\n \u003cp\u003eAdditionally, interpreters and managers reported making three adaptations to the training in their practice. The first, was extending the training insights beyond mediating cognitive assessments to interpreting jobs in the broader mental health and aged care settings.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eIt\u0026apos;s [training] not only applicable, you know, to dementia. It could be other similar scenarios \u0026hellip; especially in the space of mental health \u0026hellip; when patients are, some of them are taking lots of medication and then, you know, their mental health is a bit impaired and they can become a bit aggressive or not be fully aware of what they\u0026apos;re saying in that moment. So, mainly around how to deal with information that you can\u0026apos;t really understand sometimes. Cases like that we have a lot (\u003cem\u003eInterpreting agency manager 1, 1 year of experience\u003c/em\u003e).\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe second adaptation was in strengthening interpreter\u0026rsquo;s roles in their communities as advocates for dementia. Many noted that there was limited knowledge of dementia in ethnically diverse communities with misconceptions and community stigma delaying seeking health and aged care services. Interpreters valued the training for providing them with knowledge that they could use to promote community awareness, so that those caring for a person with dementia can better support their family member and show greater empathy:\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eI had friends complaining about, you know, they no longer wanted to spend time with their mothers because \u0026ldquo;My mother\u0026apos;s gone. She\u0026apos;s just, you know, she\u0026apos;s not my mother-in-law anymore.\u0026rdquo; And I said, \u0026ldquo;No, no, your mother is still there. She\u0026apos;s just unwell, you know? And she needs your love and support and understanding\u0026rdquo; \u003cem\u003e(Vietnamese interpreter, 27 years\u0026rsquo; experience).\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe third adaptation of the training \u0026ndash; originally designed to cover spoken languages \u0026ndash; was its application by sign language interpreters known as Auslan interpreters in Australia. They described several specific challenges related to signed languages not covered by the training such as differences in establishing trust and rapport, a need to be cognisant of body language and maintain eye contact, how to proceed if the client has not processed the sign correctly, and broader issues around proficiency and acquisition of the sign language and the age at which the client learnt sign language. They suggested including a specific Auslan section, including the code of ethics, and tests and questionnaires which might be more appropriate for use in the Auslan population.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThere was a little bit that, like, you know, sitting next to the person where we sit opposite, you know, and, and just those subtleties on what what we do... We\u0026apos;ve got our our own separate Auslan interpreter organization, and we follow our [own] code of ethics \u003cem\u003e(Auslan interpreter, 25 years\u0026rsquo; experience).\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eOne of the main topics for me that wasn\u0026apos;t included in those pre and [debriefing] were how there are severe limitations working in a signed language, interpreting some of the elements of the RUDAS \u0026hellip; So, you can\u0026apos;t just show someone an instruction in English because Auslan is not English on the hands, it\u0026apos;s got its own grammar, it\u0026apos;s got its own, you know, syntax \u003cem\u003e(Auslan interpreter, 15 years\u0026rsquo; experience)\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eMaintenance\u003c/h2\u003e\n \u003cp\u003eManagers and interpreters noted that population ageing, particularly within ethnically diverse communities, is reshaping the demand for interpreting, with dementia and aged care assessments becoming increasingly common. They suggested that if newer booking systems could prioritise interpreters who had completed the training, it would incentivise further uptake amongst interpreters. They also suggested integrating the training into their own agency\u0026rsquo;s learning management systems and making the training compulsory.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThe systems that we work with at the moment are not helpful when we\u0026apos;re choosing interpreters that have particular qualifications \u0026hellip; However, we\u0026apos;re in the process of getting new systems and in these systems, we\u0026apos;ll be able to identify if people have done specific training \u0026hellip; So, I think that, you know, going forward, interpreters will learn that, you know, there are lots of agencies out there that are saying that if you\u0026apos;ve done this training, you know, you\u0026apos;ll be offered the job first \u003cem\u003e(Interpreting Agency Manager 2, 20 years\u0026rsquo; experience).\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThese views were reinforced by clinicians who had not heard about the training before being involved in the study, but who saw the value in knowing which interpreters had done the training as this would give clinicians greater confidence in the interpreter\u0026rsquo;s skill in this area, and possibly enable them to be more targeted during the briefing.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eSo, if there\u0026apos;s, you know, an ability to say, you know, we only want to interpreters that have done this training, I think that\u0026apos;ll be really useful and would give the clinicians using these interpreters a lot more faith and trust. [\u0026hellip;] And [clinicians] having an understanding I suppose, of what training the interpreters have had too is good because then they can, I suppose, possibly save time and be able to explain things in a slightly better and more nuanced way \u003cem\u003e(Clinician 3: Geriatrician, 2 years\u0026rsquo; experience).\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eOverall, training was seen to strengthen interpreters\u0026rsquo; understanding of the aged care system and healthcare professionals working in this system. As such there was widespread enthusiasm from the sector for the training to continue beyond the lifecycle of the study. Therefore, from mid-March 2025 the training was established to the NAATI portal where it remains freely available to any interpreter in Australia and New Zealand.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs of 30 June 2024, there were 7,481 interpreters with NAATI credentials [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Of this quantum, it was estimated by our industry partners that approximately 6,000 were actively working as interpreters in the health, aged care, and/or community services sector. Thus, by the conclusion of the 12-month implementation study period, 867 or 14.5% of Australia\u0026rsquo;s active interpreter workforce had completed the training.\u003c/p\u003e \u003cp\u003eThese are world-first results as a study of this kind has never been completed before. Previous work has highlighted the impact interpreters can have on the accuracy of cognitive assessments [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and developed training that showed improvements in knowledge and confidence in interpreting skills [\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, small sample sizes of less than 100 have characterised this work [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and prior to national implementation, our trial with 126 interpreters had the largest sample to date [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This novel study offers a model for replication in other settings as well as with different disease conditions.\u003c/p\u003e \u003cp\u003eOur results were realised through several mechanisms. We engaged with our industry partners from the study\u0026rsquo;s inception and operationalised their advice in our study design, including codesigning the training with interpreters, clinicians, and ethnically diverse family carers of people with dementia [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. During the development and trialling of the training, we sustained our engagement with our partners and the broader sector via two to three annual meetings so that when it came to national implementation in the third and fourth years of the study, we had built coalitions and networks to promote the training [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScalability and promotion of the training was also achieved by using multiple channels (e.g., industry newsletters, social media) to raise awareness of the training, and keeping it online, no cost, offering PD points as an incentive, streamlining the assessment, and offering timely reminders and technical support.\u003c/p\u003e \u003cp\u003eWhile the sustainability of the training is supported by its free availability on the NAATI website, uptake may decline without ongoing promotion. A ceiling effect may also limit participation, particularly among interpreters who are not intrinsically motivated. This may be partly supported by the finding that those without NAATI credentials were less likely to complete the training, however, there could be other reasons for this. The absence of remuneration for training, additional loading for complex work, and prioritisation of trained interpreters in booking systems underscores structural issues within the interpreting and aged care sectors that extend beyond the scope of a single study to resolve.\u003c/p\u003e \u003cp\u003eIt is important to address these structural issues as interpreters and managers reported that the training enhanced interpreters\u0026rsquo; ability to mediate assessments, collaborate effectively with clinicians, apply medical terminology, recognise diverse dementia presentations, and address prior misconceptions. Professionally, these insights were extended to their performance of mental health and aged care assessments, and privately, to advocating for the greater inclusion of people with dementia in their communities combating the stigma associated with the condition.\u003c/p\u003e \u003cp\u003eHowever, clinicians remained unaware of the training and were equivocal about whether it had any impact on the performance of interpreters they worked with. This finding could be a byproduct of scale \u0026ndash; i.e., as more interpreters complete the training, its effects will be more noticeable. It could also be influenced by hierarchy and fit \u0026ndash; i.e., there are power imbalances between clinicians and interpreters with the former group not immediately aware of the latter group\u0026rsquo;s qualifications, and interactions between the pair being relatively transactional [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBroader constraints within the health and aged care system, such as time and resources, may limit the full application of the training in the interpreter\u0026rsquo;s practice as was the case with briefings and debriefings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. As interpreters reported, briefings were rarely completed, highlighting the need for raising awareness amongst clinicians and the wider dementia assessment team about its importance in a supported and constructive way. Though not touched on in this article (it will be in a later publication), clinicians themselves identified a need to receive training on how to work collaboratively with interpreters, a gap also identified by interpreters and managers in our study.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDue to the casualised nature of the interpreter workforce [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and the national scope of the study, in which the training was made available to all interpreters in Australia, agency managers were not involved in its delivery or in monitoring staff uptake. As a result, adoption varied widely across organisations, with only unreliable estimates available from participants. Similarly, NAATI and our industry partners cannot reliably track how many interpreters are currently active in the workforce. Workforce numbers are estimated from the total number of credentialed interpreters; however, many individuals retain their credentials even after retiring, leaving the industry, or moving overseas, which inflates the apparent size of the workforce. Thus, there is a possibility we have underestimated or overestimated the reach of our training. Another limitation is that neither the trial or implementation study observed interpreters while they interpreted a cognitive assessment in \u0026lsquo;real life,\u0026rsquo; which means evidence about effectiveness comes from simulations, quiz scores, and interviews.\u003c/p\u003e \u003cp\u003eParticipants who were clinicians were predominantly from Victoria and overall, participants lived in urban areas. While this corresponds with where most of Australia\u0026rsquo;s multilingual populations reside [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], we may have excluded important perspectives from other states and regional and rural areas. Finally, we did not interview ethnically diverse family carers or patients with dementia, who might have had differing views about the quality of the interpreter-mediated communication. Their interactions with interpreters during cognitive assessments are often limited to a single encounter, and a Cochrane review [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] has highlighted substantial discordance between patient or carer satisfaction and the actual quality of interpreter communication. Moreover, ethnically diverse patients and carers frequently describe this stage of the diagnostic process as highly stressful and burdensome [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTimely dementia diagnosis is influenced by patient, clinician, and health systems factors outside the interpreter\u0026rsquo;s control. It is overreaching to impute improvements in these outcomes from only interpreter training. But as a composite picture, greater than the sum of its parts, this novel, world-first study provides insights into how to improve the quality of interpreter communication in dementia assessments, ultimately facilitating more timely diagnosis and post-diagnostic care for ethnically diverse people living with dementia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMINDSET: The Improving Interpreting for Dementia Assessments Study\u003c/p\u003e\n\u003cp\u003eNAATI:\u0026nbsp;National Accreditation Authority for Translators and Interpreters\u003c/p\u003e\n\u003cp\u003ePD: Professional development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYE: Years of Experience\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis research study was conducted in adherence with the Declaration of Helsinki. The study was approved by the University of Western Australia (HREC#2021-0477), and the National Aging Research Institute provided governance approval. All participants provided informed consent.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eClinical trial number\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eEGG reported receiving grant funding to RMIT University from the Australian National Health and Medical Research Council (NHMRC), administered by the National Ageing Research Institute, to complete interpreter testing and remunerate the assessors who evaluated the performance of the interpreters during the conduct of the study (at the time the grant was awarded, the Australian Institute of Interpreters and Translators [AUSIT] was one of the research partners, and EGG was the president of this professional association); the AUSIT also provided in-kind support for the project. L-FL reported receiving grants from the NHMRC and Medical Research Future Fund, nonfinancial support from Dementia Alliance International and ADNeT, and personal fees from Roche outside the submitted work. No other disclosures were reported.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe study was funded by grant APP2005759 from the NHMRC (Profs Brijnath, Low, LoGiudice and Woodward-Kron and; Drs Enticott, Gonzalez, Gilbert, Hlavac, Antoniades, Lin, Hwang, and White) and by the NHMRC Boosting Dementia Leadership Development Fellowship to support work on the MINDSET study (Dr Low) and was supported either financially or in-kind by NAATI, AUSIT, Dementia Australia, New South Wales Health Care Interpreting Service, All Graduates Interpreting and Translation Services, Commonwealth Department of Home Affairs Translation and Interpreting Service, the Commonwealth Department of Health, Disability, and Ageing, Televic, and the Migrant and Refugee Health Partnership (all to Prof Brijnath).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe funders had the following roles in the study:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe NHMRC, Dementia Australia, Migrant and Refugee Health Partnership, Televic, and Commonwealth Department of Health, Disability, and Ageing: No role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/li\u003e\n \u003cli\u003eNAATI, AUSIT, New South Wales Health Care Interpreting Service, All Graduates Interpreting and Translation Services, and Commonwealth Department of Home Affairs Translation and Interpreting Service: Contributed to promoting the training, providing PD points (NAATI), and encouraging interpreters and managers to participate in interviews. These partners had no role in the analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eThe concept and design of the study were developed by Brijnath, Enticott, Gilbert, Gonzalez, Low, LoGiudice, Woodward-Kron, Antoniades, Hwang, and White. Data acquisition, analysis, and interpretation were undertaken by Brijnath, Clarke, Markusevska, and Cavuoto. The manuscript was drafted by Brijnath and Cavuoto, and critically reviewed for important intellectual content by Clarke, Markusevska, Enticott, Gilbert, Gonzalez, Hlavac, Low, LoGiudice, Antoniades, Lin, White, and Hwang. Statistical analyses were conducted by Markusevska and Cavuoto. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCiobanu RO. Ageing in diverse societies. In: Charest \u0026Eacute;, Kuptsch C, editors. The future of diversity. Geneva: International Labour Organization; 2021. p. 135-49.\u003c/li\u003e\n\u003cli\u003eWilkinson L. A demographic overview of ethnic diversity in Canada. Immigration, racial and ethnic studies in 150 years of Canada: Brill; 2018. p. 103-28.\u003c/li\u003e\n\u003cli\u003eAustralian Bureau of Statistics. Cultural diversity in Australia, 2021: Australian Government; 2022. https://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/2071.0%7E2016%7EMain%20Features%7ECultural%20Diversity%20Article%7E60. Accessed 14 October 2025. \u003c/li\u003e\n\u003cli\u003eTemple J, Wilson T, Brijnath B, Radford K, LoGiudice D, Utomo A, et al. The role of demographic change in explaining the growth of Australia\u0026apos;s older migrant population living with dementia, 2016\u0026ndash;2051. Australian and New Zealand Journal of Public Health. 2022;46(5):661-7.\u003c/li\u003e\n\u003cli\u003eGoth US, Str\u0026oslash;m BS. Language disintegration: communication ability in elderly immigrants with dementia. Lancet Public Health. 2018;3(12):e563.\u003c/li\u003e\n\u003cli\u003eGove D, Nielsen TR, Smits C, Plejert C, Rauf MA, Parveen S, et al. The challenges of achieving timely diagnosis and culturally appropriate care of people with dementia from minority ethnic groups in Europe. Int J Geriatr Psychiatry. 2021;36(12):1823-8.\u003c/li\u003e\n\u003cli\u003eHaralambous B, Tinney J, LoGiudice D, Lee SM, Lin X. Interpreter-mediated cognitive assessments: who wins and who loses? Clin Gerontol. 2018;41(3):227-36.\u003c/li\u003e\n\u003cli\u003eNHMRC Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People. Clinical practice guidelines and principles of care for people with dementia. Sydney: National Health and Medical Research Council; 2016.\u003c/li\u003e\n\u003cli\u003eKasten MJ, Berman AC, Ebright AB, Mitchell JD, Quirindongo-Cedeno O. Interpreters in health care: a concise review for clinicians. Am J Med. 2020;133(4):424-8.e2.\u003c/li\u003e\n\u003cli\u003ePlejert C. Challenges and remedies for interpreter-mediated dementia assessments. In: Gavioli L, Wadensjö C, editors. The Routledge handbook of public service interpreting. First edition. New York, NY: Routledge; 2023.\u003c/li\u003e\n\u003cli\u003eTorkpoor R, Fioretos I, Ess\u0026eacute;n B, Londos E. \u0026quot;I know hyena. do you know hyena?\u0026quot; Challenges in interpreter-mediated dementia assessment, focusing on the role of the interpreter. J Cross Cult Gerontol. 2022;37(1):45-67.\u003c/li\u003e\n\u003cli\u003eGilbert AS, Croy S, Hwang K, LoGiudice D, Haralambous B. Video remote interpreting for home-based cognitive assessments. Interpreting. 2022;24(1):84-110.\u003c/li\u003e\n\u003cli\u003eGilbert AS, Antoniades J, Hwang K, Gonzalez E, Hlavac J, Enticott J, et al. The MINDSET study: co-designing training for interpreters in dementia and cognitive assessments. Dementia. 2023;22(7):1604-25.\u003c/li\u003e\n\u003cli\u003eBrijnath B, Markusevska S, Enticott J, Sethi P, Gilbert AS, Gonzalez E, et al. Interpreter communication quality in cognitive assessments for dementia: the mindset randomized clinical trial. JAMA Network Open. 2025;8(2):e2458069-e.\u003c/li\u003e\n\u003cli\u003eGlasgow RE, Estabrooks PE. Pragmatic applications of RE-AIM for health care initiatives in community and clinical settings. Prev Chronic Dis. 2018;15:E02.\u003c/li\u003e\n\u003cli\u003eHoltrop JS, Rabin BA, Glasgow RE. Qualitative approaches to use of the RE-AIM framework: rationale and methods. BMC Health Serv Res. 2018;18(1):177.\u003c/li\u003e\n\u003cli\u003eBrijnath B, Gonzalez E, Hlavac J, Enticott J, Woodward-Kron R, LoGiudice D, et al. The impact of training on communication quality during interpreter-mediated cognitive assessments: Study protocol for a randomized controlled trial. A\u0026amp;D: TRCI. 2022;8(1):e12349.\u003c/li\u003e\n\u003cli\u003ePinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795.\u003c/li\u003e\n\u003cli\u003eEser O. Challenges facing the community interpreting industry. Understanding community interpreting services: diversity and access in Australia and beyond. Cham: Springer International Publishing; 2020. p. 43-78.\u003c/li\u003e\n\u003cli\u003eHlavac J. The development of community translation and interpreting in Australia: a critical overview. Translating and Interpreting in Australia and New Zealand. 2021:65-85.\u003c/li\u003e\n\u003cli\u003eBeinchet A, Taibi M. Community translation and interpreting under neoliberal agendas: the cases of Australia and Canada. In: Jalalian Daghigh A, Shuttleworth M, editors. Translation and Neoliberalism. Cham: Springer Nature Switzerland; 2024. p. 99-118.\u003c/li\u003e\n\u003cli\u003eLai M, Costello S. Professional interpreters and vicarious trauma: an Australian perspective. Qual Hlth Res. 2021;31(1):70-85.\u003c/li\u003e\n\u003cli\u003eCrezee I. Teaching interpreters about self-care. IJIE. 2015;7(1):7.\u003c/li\u003e\n\u003cli\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.\u003c/li\u003e\n\u003cli\u003eNowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods.2017;16(1):1609406917733847.\u003c/li\u003e\n\u003cli\u003eNational Accreditation Authority for Translators and Interpreters. NAATI Annual Report 2023-2024. Canberra: NAATI; 2024.\u003c/li\u003e\n\u003cli\u003eMajlesi AR, Plejert C. Embodiment in tests of cognitive functioning: a study of an interpreter-mediated dementia evaluation. Dementia. 2018;17(2):138-63.\u003c/li\u003e\n\u003cli\u003ePlejert C, Lindholm C, Schrauf RW. Multilingual interaction and dementia: multilingual matters. Bristol; 2017.\u003c/li\u003e\n\u003cli\u003eOno N, Kiuchi T, Ishikawa H. Development and pilot testing of a novel education method for training medical interpreters. Patient Educ Couns 2013;93(3):604-11.\u003c/li\u003e\n\u003cli\u003eFioretos I, Torkpoor R. Inga om men eller varf\u0026ouml;r: Att fr\u0026auml;mja s\u0026auml;ker och j\u0026auml;mlik kognitiv utredning genom tolk. : Kunskapscentrum demenssjukdomar, Migrationsskolan. 2019.\u003c/li\u003e\n\u003cli\u003eZhang CX, Crawford E, Marshall J, Bernard A, Walker-Smith K. Developing interprofessional collaboration between clinicians, interpreters, and translators in healthcare settings: outcomes from face-to-face training. J Interprof Care. 2021;35(4):521-31.\u003c/li\u003e\n\u003cli\u003eCarlson ES, Barriga TM, Lobo D, Garcia G, Sanchez D, Fitz M. Overcoming the language barrier: a novel curriculum for training medical students as volunteer medical interpreters. BMC Med Edu. 2022;22(1):27.\u003c/li\u003e\n\u003cli\u003eAbdulkadir LS, Sodemann M, Gudex C, M\u0026ouml;ller S, Nielsen DS. The impact of a health introduction course for medical interpreters in the healthcare sector. Nord. J. Nurs. Res. 2020;41(2):109-16.\u003c/li\u003e\n\u003cli\u003eWHO. Practical guidance for scaling up health service innovations. Geneva; 2009.\u003c/li\u003e\n\u003cli\u003eNielsen TR, Franzen S, Watermeyer T, Jiang J, Calia C, Kj\u0026aelig;rgaard D, et al. Interpreter-mediated neuropsychological assessment: Clinical considerations and recommendations from the European Consortium on Cross-Cultural Neuropsychology (ECCroN). Clinical Neuropsychologist. 2024;38(8):1775-805.\u003c/li\u003e\n\u003cli\u003eWang S, Sun QC, Martin C, Cai W, Liu Y, Duckham M, et al. Tracking the settlement patterns of culturally and linguistically diverse (CALD) populations in Australia: a census-based study from 2001 to 2021. Cities. 2023;141:104482.\u003c/li\u003e\n\u003cli\u003eTsuruta H, Karim D, Sawada T, Mori R. Trained medical interpreters in a face‐to‐face clinical setting for patients with low proficiency in the local language. Cochrane Database Syst Rev. 2016(5).\u003c/li\u003e\n\u003cli\u003eLoGiudice D, Hassett A, Cook R, Flicker L, Ames D. Equity of access to a memory clinic in Melbourne? Non-English speaking background attenders are more severely demented and have increased rates of psychiatric disorders. Int J Geriatr Psychiatry. 2001;16(3):327-34.\u003c/li\u003e\n\u003cli\u003eNHMRC National Institute for Dementia Research (NNIDR). Culturally and linguistically diverse (CALD) dementia research action plan: Full report. Canberra: NNIDR; 2020.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Interpreter training, cognitive assessment, dementia, healthcare equity, ethnic diversity","lastPublishedDoi":"10.21203/rs.3.rs-8208390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8208390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAs Australia\u0026rsquo;s ethnically diverse population ages, dementia prevalence is rising. Professional interpreter support is essential to ensure equitable access to accurate dementia diagnosis and care. To address this need, a nationally specialised online, self-paced training on dementia and cognitive assessments was developed for interpreters. Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, this article reports on the training\u0026rsquo;s implementation. Specifically, it explores the training\u0026rsquo;s reach, barriers and facilitators to adoption, effectiveness in improving interpreter-mediated assessments, and potential for long-term maintenance.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween 24 November 2023 and 12 December 2024, the online self-paced training was rolled out to interpreters nationally across Australia. Implementation was supported by industry study partners, including interpreter agencies, advocacy organisations, a technology partner, and the national accreditor for interpreters. A mixed-methods evaluation was undertaken. Quantitative monitoring captured the training\u0026rsquo;s reach, uptake, and successful completion. In parallel, qualitative interviews were conducted with 24 interpreters who completed the training, 6 managers from interpreter agencies, and 16 clinicians who worked with interpreters to undertake cognitive assessments. Quantitative data were descriptively analyzed, and qualitative data were analyzed using the framework method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e865 interpreters, representing 14.4% of Australia\u0026rsquo;s active interpreter workforce, completed the training. Interpreters and agency managers reported that the training improved interpreter practice and confidence. In contrast, clinicians were unaware of the training. Barriers to uptake included time constraints, technical issues and limited computer literacy, and the perceived difficulty of the content for some participants. Key facilitators included ease of access (being online and no cost), incentive of professional development points, a straightforward final assessment, and administrative support. The training has now been made freely and permanently available on the national accreditation authority\u0026rsquo;s website.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis world-first study demonstrates a scalable approach to delivering interpreter training for dementia assessments, with the potential to enhance the accuracy and timeliness of diagnosis for ethnically and linguistically diverse people living with dementia.\u003c/p\u003e","manuscriptTitle":"Implementing interpreter training for dementia assessments at national scale using the RE-AIM framework: A mixed-methods evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-19 18:18:37","doi":"10.21203/rs.3.rs-8208390/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-07T07:23:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-07T06:05:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1920963921961793034695792405073733185","date":"2026-01-03T08:49:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240203065060181781067417949581907789182","date":"2026-01-02T13:46:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-24T02:57:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334291447860136818736903556506454844417","date":"2025-12-20T01:18:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-18T01:08:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-18T01:05:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-09T10:08:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-07T23:11:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-12-07T23:04:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"511f10f7-2ae7-4d66-a42c-8320790d690b","owner":[],"postedDate":"December 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:05:56+00:00","versionOfRecord":{"articleIdentity":"rs-8208390","link":"https://doi.org/10.1186/s12877-026-07238-8","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2026-03-05 15:59:55","publishedOnDateReadable":"March 5th, 2026"},"versionCreatedAt":"2025-12-19 18:18:37","video":"","vorDoi":"10.1186/s12877-026-07238-8","vorDoiUrl":"https://doi.org/10.1186/s12877-026-07238-8","workflowStages":[]},"version":"v1","identity":"rs-8208390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8208390","identity":"rs-8208390","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}