My mother speaks English
In 2017, my fiercely independent 89-year-old mother went to our local hospital to have a vascular surgeon examine a foreboding ulcer developing on her ankle.
I made an appointment at the vascular clinic. My mother wanted to handle the doctors herself. I’m her primary caregiver, but over the years I’ve always given her agency over her own healthcare decisions. As a product of colonial India, she speaks English well enough, though sometimes American accents and phrasing confuse her.
Sitting outside the cubicle as the surgeon and his crew examined her, the faint murmur of conversation filtered through the thin plastic curtain. I sensed a note of acquiescence in the tone of my mother’s voice.
When she emerged 45 minutes later with a unaboot on each leg, Mom looked confused and uncomfortable. She said the doctor had assured her it was for the best, despite her misgivings. A week later when she went back to have the unaboot replaced, the outer layer of her extremely sensitive skin came away with the dressing. Her legs bear those scars to this day, and my once-independent mother refuses to see any physician unless I’m with her to advocate for her healthcare.
English language challenges
Older immigrant parents like my mother often encounter challenges speaking up for their healthcare needs. According to U.S. census data, language barriers have been associated with limited access to health care and poor health outcomes. Though my mother does speak English, she found the surgeon’s manner intimidating and felt it challenging to articulate her point of view.
For non-English speaking patients, that challenge is exacerbated. At a July 21st EMS briefing, health advocates debated the troubling aspects of language barriers in healthcare access.
Dr. Latha Palaniappan of Stanford University’s Center for Asian Research and Education (CARE) found that non-English-speaking patients reported receiving less health education, worse care, and lower patient satisfaction They often receive less preventive care compared to their English-speaking counterparts, and face greater challenges in accessing health care.
The future of immigrant America
As America grows more racially and ethnically diverse, U.S. census data reports that from 1980 to 2019, the number of people in the U.S. who spoke a language other than English at home nearly tripled to well over 67 million. More than 14 million people in the United States do not speak English and more than 25 million people say they speak less than well. These groups are often referred to as speakers with Limited English Proficiency (LEP).
With the number of non-English speaking patients projected to increase in the U.S., it becomes crucial to develop innovative methods to facilitate communication between clinicians and patients.
Obstacles hindering access to care
Dr. Palaniappan’s research focuses on Asian, Hispanic, and African American populations in the United States. Language and language access are important social determinants of health, she explained. Language barriers often occur when healthcare providers and patients do not share a native language. This hampers communication between patient and provider.
“I want to emphasize that language proficiency does not necessarily mean medical proficiency,” adds Dr. Palaniappan, when some doctors state that they have language proficiency on their websites. It may only mean they are colloquially and conversationally proficient in a language, but not in medical terms.
The American Community Survey identified the top limited English speakers by household as primarily Asian. They include Mandarin, Cantonese, Korean, and Vietnamese – origin households, followed by Russian and Slavic-speaking households.
Obstacles to Interpretative Services
Patients and families with limited English proficiency (LEP) face health disparities due to many such factors.
In the survey, both patients and providers reported less than satisfactory access to adequate interpretation services that in many healthcare systems, is caused by cost-cutting measures. Telephone translation is not as ideal, said Dr.Palaniappan because it eliminates nonverbal cues. Sometimes there’s a two-hour wait to get a telephone translator on the line, while remote services with video are hamstrung by limited access to internet services and bandwidth.
Dr. Elaina B. Rios, President and CEO of the National Hispanic Medical Association pointed out that with so few physicians of Hispanic, black, or Native American ethnicity, “you don’t get the racial concordance between doctors and patients. And so sometimes that’s the problem.”
Negative health outcomes
LEP populations have trouble navigating local healthcare systems. This leads to delays in reporting symptoms, not receiving timely care, and higher rates of undiagnosed conditions.
People with limited English proficiency are 2.4 times more likely to have problems understanding a medical situation and twice as likely to have a bad reaction to medication due to problems understanding instructions.
This happens, warned Dr. Palaniappan, when for example, a physician tells a patient to get a colonoscopy, but all materials on how to prepare for a colonoscopy, the bowel prep, and instructions after the colonoscopy, are largely written in English. Or, if a patient is not using an inhaler properly, he/she is more likely to have an asthma attack, and 1.9 times more likely to have an adverse physical event leading to major harm or death.
LEP populations have more infections, falls, surgical site infections, pressure injuries, delays, and surgery, problems with medication management, and decreased preventive screening like mammograms.
In a recent CDC study, epidemiologist Dr. Ingrid J. Hall from the Centers for Disease Control and Prevention, found that only 69% of Hispanics with limited comfort speaking English had a regular provider. Hispanic adults are less likely to receive timely cancer screenings said Dr. Hall. They have “even lower screening prevalence reported amongst the recent immigrants, those who are less acculturated, are those showing less adaptation to American life.”
So, language barriers urgently need to be addressed to improve care for people with limited English proficiency.
Solutions to remove barriers
One solution is to translate materials into the patient’s preferred language. Dr. Palaniappan is working with Dr. Jason Hong, a colleague at Stanford, to translate diabetes materials into multiple languages with their healthcare system. Another initiative is translating after-visit EPIC (electronic healthcare system) summaries for patients which are currently all in English, into different languages.
Dr.Palaniappan also is working to integrate HIPAA-compliant translation tools in tandem with interpretation services to improve healthcare delivery and patient safety, and decrease costs.
She added that Section 1557 of the Affordable Care Act requires healthcare services to provide qualified interpreting services free of charge. Though family members and friends can serve as informal interpreters, LEP patients need a qualified interpreter to navigate the medical process.
“We’re finding is that in-person interpretation, combined with telephone, or video-based interpretation can be cost-effective and more efficient in delivering care to limited English proficient patients,” said Dr. Palaniappan.
The cultural component
In South Asian families like mine, which live in multigenerational households, adult children like me are closely involved in the healthcare process for our parents.
After my mom’s disastrous unaboot episode, I became her healthcare proxy. I now attend every physician visit, answer questions and mediate on her behalf. Her relief is palpable. I know many South Asian families in similar situations have children advocating for their LEP parents.
“When people get sick, especially elderly, they, they revert back to their language, they have comfort,” said Dr. Rios.
An important step is to take into account cultural nuances and ensure the team is on the same page when communicating with patients and preparing treatment plans, said Dr. Palaniappan. While Western medicine takes an individualistic approach, diagnoses, new therapies, and treatment plans should be communicated with the cooperation of the family.
Where are my mom’s teeth and other long-term care issues
The care continuum is interrupted for a patient with limited English proficiency in long-term care, said Dr. Palaniappan. While a physician may have access to interpreter services, other medical personnel may not. So, if a nurse or medical assistant comes in to take vital signs, change the sheets, or bathe a patient, communicating the right information to a patient can be challenging.
Sandy Wilson who worked as a long-term care home inspector confirmed that LEP patients were more at risk in care homes. If a patient advocate is not present, a patient got lower levels of care. “Their diapers may not get changed on time. If a patient’s false teeth get lost in the bedsheets, they could end up in the washing machine. There’s no irate son or daughter there to ask, ‘What’s happened to my mum’s teeth?”
Worryingly, carers who are poorly paid to begin with, take shortcuts to do the bare minimum possible, said Wilson. “If there wasn’t a camera in the room, they may not wash their hands before tending to a patient.” A non-English speaker would not be able to advocate for themselves in such circumstances.
Artificial intelligence in translation services
Will cost-cutting health providers turn to artificial intelligence as their solution to language access?
Dr. Palaniappan suggested that AI could augment and serve as an adjunct to translation services. Her study used Chat GPT for diabetes and found that it was 75% accurate. “Obviously it can’t replace a care provider but can definitely be a good adjunct. So, these all have to be well vetted before they’re deployed in healthcare systems.”
For now, my mom takes comfort in the fact that her daughter rather than an unfamiliar translator or AI entity, ensures she gets the care she wants. But many LEP seniors without an advocate in their corner, face a medical future at the mercy of an unforgiving language barrier.