by Jackelyne Abranches
Jackelyne Abranches is an exercise and health sciences major from Everett, MA. She says that this essay was inspired by her firm belief that language should never hinder someone’s access to quality healthcare. Jackelyne’s career goals revolve around “breaking down these language barriers and many others to ensure equal health opportunities for everyone.” As a first-generation American, she grew up observing various health challenges faced by her Brazilian family members. She says that “witnessing their struggles has deeply impacted me, and it is this first-hand experience that fuels my passion for ensuring equitable access to healthcare for all immigrants.” Jackelyne’s passion comes from her family and community who encourage her during her college journey. Her ultimate aim is to reciprocate their support by becoming a physician’s assistant and extending equal care and assistance to underprivileged communities.
Could you really die because you don’t know how to speak English? Alright, maybe “die” is a strong word, but there can be serious consequences to your health by not speaking English. As a first-generation member of my household, I was crowned the unofficial “official translator” of all official documents, school enrollment forms, and most importantly, doctor’s visits. If anyone in my family had a doctor’s appointment, I’d get a pass from school and a lengthy visit to the doctor’s where my tiny brain had to translate English to my Portuguese-speaking family members. It was a fun no school day for me, but not always fun for my family members. For instance, my aunt, who only speaks Portuguese, had to go to the hospital for abdominal pain. Despite having Spanish-speaking staff members present, not having Portuguese-speaking staff members limited the critical information that could be explained to my aunt. As a result of limited communication, my aunt was unable to fully express the severity of her pain and was given a lower dosage of pain medication than needed. So, I was brought to the next doctor’s appointment to help advocate and translate. This time, we discovered my aunt’s condition was more severe than meets the eye, and tests were taken to determine a proper diagnosis. However, not everyone has a niece they can bring to doctor’s appointments when needed, and not every doctor has a medical translator on hand for the required language.
Language barriers have a significant impact on the quality of care a patient receives, particularly in a country where 64.7 million people speak another language other than English. According to the Migration Policy Institute (MIP), as of 2015, only 60% of those living in the United States who speak “a foreign language at home were fully proficient in English” and of these bilingual individuals, “more than 25.9 million people were [classified] LEP” or limited-English proficiency, meaning their primary language is not English and/or they have a limited ability to read, write, speak or understand English (Batalova, J., & Zong, 2016). The prevalence of LEP individuals underscores the need to address language barriers in healthcare settings, where misdiagnoses, readmissions, and other complications can arise due to communication breakdowns between providers and patients. These statistics stress the importance of recognizing the differences and language barriers. But knowing about an issue can only do so much; we must work towards it. In making an act to truly understand and address the issue of language barriers in health and health care, we can provide effective care to the non-English speaking community or LEP, who may otherwise lack confidence or trust in the medical community.
One person who can attest that this is a real issue is Alexander R. Green, M.D and Chijioke Nze. In the article, “Language-Based Inequity in Health Care,” published in the Journal of Ethics. Green and Nze (2017) share their experience with LEP patients as a resident in a U.S. medical school. Green and Nze discuss a patient, Mr. S, a 56-year-old Brazilian construction worker who had recently undergone hip replacement surgery and returned due to nausea, vomiting, and food intolerance post-surgery. Green says the patient’s medical chart had labeled him as a “poor historian” (Green & Nze, 2017, p. 263). Although not explicitly said in Green’s article, a simple Google search explains the term “poor historian” is used by medical professionals to describe a patient who is unable to give a clear account of their illness or symptoms. Green explains that because it was a busy night in the ER, “no one had yet involved a medical interpreter” to help communicate with Mr. S. As a result, the doctors were unable to gain vital information to provide a diagnosis and instead were “frustrated,” doubting extra time to try and communicate with Mr. S would be worthwhile (Green & Nze 2017, p. 263). Despite not speaking the patient’s language, Green took the extra time to try and communicate with Mr. S and found he had been taking the wrong medications post-surgery because he did not understand which medication he was supposed to take. Green’s experience is important because it highlights the dangerous effects of not being able to communicate with patients, while also showcasing the bias healthcare workers may have towards patients who do not speak fluent English. Despite hospital settings being very busy and fast-paced, LEP patients should not be ignored.
It doesn’t take a genius medical student to recognize these disparities. A simple Google search can lead you to articles such as the one on ABC News entitled “The Healthcare System Is Shortchanging Non-English Speakers,” in which Pooja Chandrashekar (2022) argues that we have fallen short when caring for our most vulnerable patients. Most recently, with the COVID-19 pandemic, Chandrashekar interviewed local health workers in Boston and discovered that lack of materials about the vaccine translated into multiple languages made it difficult for non-English speaking patients to protect themselves (Chandrashekar, 2022). Many state government vaccine finder websites initially only provided information in English. Lack of information in multiple languages led to many misunderstandings, poorer health outcomes in communities with people of color, and higher rates of COVID infections. In fact, even one of my family members believed that the Coronavirus was a result of drinking a few too many Corona beers, refusing to believe it was true until they got infected, proving that a lack of information being conveyed can impact the way non-English speakers understand important aspects of their health.
Another search shows that even when presented with the opportunity to get clarifying information, LEP patients are afraid to ask their providers questions. Edward Chen, of Stat News, writes in 2022: “Language barriers keep parents from asking questions about their children’s care, study finds” (Chen 2022). A survey done in 21 hospitals found that those who are not proficient in English “are less comfortable asking questions about their care” and “less likely to speak up when something does not seem right” (Chen 2022). These patients’ experiences underscore the importance of patient empowerment and the need for LEP individuals to feel comfortable asking questions and speaking up about their care. Without this, they may not fully understand their diagnosis or treatment options, which can lead to poor health outcomes. Additionally, Chen’s (2022) study highlights the need for greater cultural competency among healthcare providers. Providers who are aware of the cultural factors that may influence a patient’s communication style and willingness to speak up can take steps to create a more welcoming and inclusive environment.
However, creating an inclusive environment takes some work. Change doesn’t happen overnight, but it’s happened before in the medical community. Take, for instance, the use of hand sanitizers before entering a patient’s room. Before the 1990s, this was not a common practice, as it is today. Recently, however, hand sanitizers have been made available outside every patient’s room for healthcare workers to use before walking into a room (World Health Organization, 2009). This example shows that change can happen, despite it being rigorous, if the need presents itself. So far, we have recognized the need: language barriers can result in miscommunication, misunderstandings, and medical errors, negatively affecting the quality of care and health outcomes for LEP patients. Yet there is still much to understand about this debate. What accommodations are available for LEP patients? How effective are these methods? And what more can be done to ensure equitable quality care for all? Let’s find out!
One solution already put into practice is the use of professional medical interpreters. Medical interpreters are trained professionals who help bridge the language divide between a patient and the medical provider to facilitate communication between both parties and ensure patients receive the care they need, while providers can understand and properly address patients’ concerns. Dr. Leah S. Karliner et al. (2007), in “Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency?” conducted a study with several non-English speaking patients and many different methods, including in-person untrained interpreters, in-person trained interpreters, and telephonic interpreters. Their findings reveal that the use of in-person “professional interpreters and bilingual staff have been found to improve health care access, satisfaction, and quality for LEP patients” (Karliner et al., 2007, p. 748). Yet even though the majority found an interpreter to be helpful, there were case studies that identified “a worrisomely high error rate (53 percent) for professional interpreters” (Karliner et al., 2007, p. 736 ). In short, professional interpreters can be useful, but that is not always the case. The lack of diverse and multilingual staff can cause a burden for patients. Additionally, medical interpreters are not always available, which is why there were ‘untrained interpreters’ included in Karliner et al.’s case study. The lack of staffing and high error rate indicates that although this may be the best option in some instances, it is not always an available resource, promoting the need to hire more diverse staff.
As mentioned previously, in-person interpreters are not always available. Therefore, healthcare workers must think outside the box. One example of this is the use of visual aids. Just like the 1-10 scale with the smiley faces used in pediatric offices to have a child describe their pain level, visuals can also be used with older adult patients. Karliner et al., in the same article, also researched if visuals were as effective as medical interpreters. Although interpreters were preferred, there is an effectiveness to the visual arts method. Their study aimed to assess the effectiveness of a visual aid tool (a flipchart) in facilitating communication with 205 LEP patients in a primary care setting. The patients were randomized to receive care either with or without the use of the visual aid tool. The results showed “visual aids can be an effective tool in facilitating communication with LEP patients, “improving comprehension of their health condition and treatment plan (Karliner et al., 2007, p. 728 ). Patients in the intervention group reported greater understanding of their medical conditions receiving a higher mean understanding score compared to the control group (4.7 vs. 4.1 on a 5-point scale), better satisfaction with the care they received (4.8 vs. 4.2 on a 5-point scale) and were more likely to adhere to recommended treatments compared to the control group (93% vs. 78%) (Karliner et al., 2007). If no medical interpreter is available, using visual aids to explain things to patients can help them understand information more effectively than if no intervention was used at all. However, visual aids require more time and effort from workers. Sometimes, in a busy setting, visuals may not always be the first option that comes to mind. It certainly was never a form of communication used with my aunt.
So how do we ensure medical professionals pay attention to their patients and make them feel comfortable? The first step is being more culturally mindful. In the beginning of this essay, I shared how the patient included by Green and Nze (2017) had “poor historian” written on his medical chart. However, the term “poor historian” is not an accurate description of that patient. We must ask, is the patient truly unable to give a clear account or are they unable to communicate their account in English? Labeling a patient a “poor historian” infers that they are unable to communicate with medical professionals, but maybe the medical professionals should be trying to understand patients better. By removing the unconscious biases we have towards LEP patients, we can move a step closer to ensuring equitable care despite the language barrier. It is possible that medical workers can change their attitudes about LEP patients and provide more equitable care by participating in cultural competency training. Cultural competency training can help medical workers develop cross-communication skills, including strategies for working with alternative forms of communication and learning to manage language barriers. This is important because by learning about other cultures, medical workers can become more empathetic to LEP patients rather than ridicule them for not knowing English. This practice can help improve the health of LEP patients by giving them a chance to have a patient and understanding provider who will take the time to aid them in understanding the information being given to them.
Furthermore, even with cultural competency training, medical workers may still hold biases and assumptions that can affect their interactions with LEP patients. It is difficult to completely eliminate biases, and medical workers may need ongoing support and education to recognize and address their own biases. Therefore, it is important for medical workers to approach each patient as an individual with unique needs and perspectives, rather than relying solely on cultural competency training as a one-size-fits-all solution. Medical workers should strive to build trusting relationships with LEP patients, communicate clearly and respectfully, and actively involve patients in their own care. These strategies can help to overcome language and cultural barriers and promote equitable care for LEP patients.
Another possible solution that can be implemented is patient-centered care. Although this is a common practice, it is often challenging with LEP patients, but should be enforced to ensure equitable healthcare services. In the research “Validation of a Patient-Centered Culturally Sensitive Health Care Provider Inventory Using a National Sample of Adult Patients,” Tucker et al. explores the idea of patient-centered care, proving that “cultural competence and cultural sensitivity of providers are positively associated with patient satisfaction” (Tucker et al, 2013, p. 344). This correlates to the patient’s satisfaction with various physician behaviors. Tucker et al. shares that:
These psychosocial aspects of healthcare quality primarily are impacted by how providers interact with their patients, which include providers’ interpersonal skills that enable patients to feel comfortable and trusting, and displaying provider behaviors and attitudes that connote sensitivity to and respect for patients. (Tucker et al, 2013, p. 348)
To put it simply, by making LEP patients feel validated and taking the time to slow things down, the health and satisfaction of LEP patients can improve and the readmission rates can be reduced. In addition to this, medical workers could use plain language and avoid medical jargon to ensure that patients understand their health conditions and treatment options. This can look like directly speaking to a patient instead of directing questions at an interpreter or slowing down when speaking English. This positive engagement allows for reinforcement in the information being shared by both parties.
In this research-based inquiry, the challenges faced by limited English proficiency (LEP) patients in accessing and receiving equitable healthcare services have been explored. The review of the literature reveals that language and cultural barriers are significant factors that impede effective communication between LEP patients and healthcare providers, leading to decreased patient satisfaction and poorer health outcomes. This review also highlights the need for a multifaceted approach to addressing the challenges faced by LEP patients in accessing and receiving equitable healthcare services. One important factor that emerged from the analysis is the need for healthcare workers to receive adequate cultural competency training to address the unconscious biases that may affect their interactions with LEP patients. However, it is also recognized that this training alone may not be enough to overcome the challenges that arise when caring for diverse populations with unique needs and perspectives. Strategies such as patient-centered care and the use of visual aids may help healthcare providers to communicate more effectively with LEP patients, but more research is needed to determine their efficacy in various healthcare settings, as well as the impact of other social determinants of health that may affect LEP patients’ ability to access healthcare services.
Looking forward, there are several questions that future research could address. For example, what are the most effective methods for healthcare providers to build trusting relationships with LEP patients, and how can these be adapted to different cultural contexts? How can healthcare organizations best leverage technology to improve access to care for LEP patients, while also ensuring that these technologies do not further exacerbate existing health disparities? Additionally, what role can policymakers and healthcare administrators play in addressing the systemic barriers that LEP patients face in accessing equitable healthcare services? Having these practices may have eliminated the missed school days I needed to help my aunt understand what was going on with her health. Moving forward, further research is needed to identify the most effective approaches for promoting effective communication and improving health outcomes for LEP patients.
References
Batalova, J., & Zong, J. (2016, November 11). Language Diversity and English Proficiency in the United States. Migration Policy Institute.
Green, A. R., & Nze, C. (2017). Language-Based Inequity in Health Care: Who Is the “Poor Historian”? AMA Journal of Ethics, 19(3), 263–271.
Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42(2), 727–754.
Mendoza, M. (2022, August 29). The Health Care System Is Shortchanging Non-English Speakers. Scientific American.
National Center on Immigrant Integration Policy. (2015). Language Diversity and English Proficiency in the United States. Migration Policy Institute.
Skerrett, P. (2023, January 24). It’s time to retire ‘poor historian’ from clinicians’ vocabularies. STAT. Retrieved April 9, 2023.
Thielking, M. (2022, June 13). Language barriers keep parents from asking questions about their children’s care, study finds. STAT. Retrieved April 9, 2023.
Tucker, C. M., Nghiem, K. N., Marsiske, M., & Robinson, A. C. (2013). Validation of a patient-centered culturally sensitive health care provider inventory using a national sample of adult patients. Patient Education and Counseling, 91(3), 344–349.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009. 4.