Getting past getting by: training culturally and linguistically competent bilingual physicians

Barriers to cervical cancer prevention in a safety net clinic: gaps in HPV vaccine provider recommendation and series completion among Ob/Gyn patients

Objective

The primary objective of this study was to evaluate patients' knowledge regarding HPV vaccination and vaccine uptake in a diverse patient population. The secondary objective was to evaluate factors influencing the decision to vaccinate, potential barriers to vaccination, and to assess whether HPV vaccines were offered to or discussed with eligible patients in a safety net Obstetrics and Gynecology (Ob/Gyn) clinic.

Methods

A 28-item survey was developed using Likert scale survey questions to assess patient agreement with statements regarding HPV and the vaccine. The surveys were administered to patients in the Ob/Gyn outpatient clinics from May 2021 through September 2022. Additionally, pharmacy data were reviewed and chart review was performed as a quality improvement initiative to assess the impact of expanded HPV vaccine eligibility to patients with private insurance on vaccine uptake. Descriptive statistics were performed.

Results

304 patients completed surveys from May 2021 through September 2022. The median age of respondents was 32 (range 18-80). 16 (5%) were Non-Hispanic White, 124 (41%) were Hispanic White, 58 (19%) were Non-Hispanic Black, 6 (2%) were Hispanic Black, 29 (9.5%) were Haitian, 44 (14%) were Hispanic Other, 7 (2%) were Non-Hispanic Other, 20 (6.6%) did not respond. 45 (14%) patients were uninsured. Many patients (62%) reported that a physician had never discussed HPV vaccination with them. Seventy nine percent of patients reported they had never received the HPV vaccine, and 69% of patients reported that lack of a medical provider recommendation was a major barrier. Among patients to whom HPV vaccination had been recommended, 57% reported that the vaccine was not available the same day in clinic.

Conclusion

Our study demonstrated that many patients never had a provider discuss HPV vaccination with them and never received the HPV vaccine. Additionally, amongst those who did initiate HPV vaccination, completion of the series remains a key barrier. Ensuring that providers discuss HPV vaccination and that patients receive HPV vaccines, along with expanding access to and convenience of HPV vaccination are critical aspects of preventing cervical cancer.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US

IMPORTANCE

Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness.

OBJECTIVE

To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?"

MAIN OUTCOMES AND MEASURES

Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics.

RESULTS

Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions.

CONCLUSIONS AND RELEVANCE

This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Resident Training Experiences Providing Spanish-Language Concordant Care: Implications for Growing Health Equity Efforts Within Graduate Medical Education

Training experiences where residents provide Spanish-language concordant care (SLCC) have not been widely described despite their increasing need and prevalence in graduate medical education. In this qualitative study, we enrolled nonnative Spanish-speaking residents (n = 21) within SLCC training clinics from 3 geographically unique programs. Participants completed semistructured interviews focused on their overall SLCC training experience. Major themes identified included (1) high levels of satisfaction in their SLCC experience, (2) concern about ongoing language barriers, (3) demonstration of high levels of cultural humility in caring for patients with limited English proficiency, and (4) identification of several valuable programmatic and clinical resources. Based on these findings, we conclude that SLCC training experiences are of significant value to trainees in becoming pediatricians able to promote health equity. Themes identified could help inform how graduate medical education programs utilize SLCC to grow health-equity based efforts to deliver more effective and compassionate care to our linguistically diverse populations.

The Parent's Perspective: A Focus Group Study on Spanish Interpreter Services for Hospitalized Children

BACKGROUND

The US Census confirms a rise in Spanish-speakers, many of whom have limited English proficiency (LEP) and require interpreters. Parent perceptions of interpreter services throughout hospitalization are unknown.

OBJECTIVE

To explore Spanish-speaking LEP parents' views regarding roles of interpreters and providers (attending, resident, or nurse) during a hospital encounter, optimal modalities of interpretation, and barriers to services.

METHODS

Spanish-speaking LEP parents of children discharged from the hospital medicine service participated in focus groups. Sessions were audio-recorded and transcribed in Spanish, translated into English, and verified for translation accuracy. Qualitative methods were used for thematic analysis.

RESULTS

Four sessions (n = 23 participants representing 15 families) were held. Parents felt the interpreter's primary role was to act as a conduit for word-for-word interpretation. They desired kind and trustworthy interpreters with medical knowledge. They saw providers as leaders of the encounter who should allot enough time for interpretation, not use Spanish unless they were fluent, and give frequent medical updates. In-person interpreters were preferred over telephone and video for their ability to convey body language and build relationships. Barriers to requesting interpreters included embarrassment and inability to directly request services, which resulted in using family members as interpreters. On family-centered rounds, parents preferred professional interpreters over bilingual providers.

CONCLUSIONS

Modifications are required to improve interpreter services to meet the needs of LEP families. Parents emphasized in-person interpreters' social skills, frequent provider updates, and additional navigation support as essential components of effective care. Next steps include implementing guidelines and interventions to optimize interpreter services.

Provider recommendation for HPV vaccination across Hispanic/Latinx subgroups in the United States

Healthcare provider recommendation is a key predictor of HPV vaccination among adolescents, yet little is known about how parents' receipt of a provider recommendation differs across Hispanic/Latinx subgroups in the United States. We analyzed data from the 2012-2016 National Immunization Survey - Teen on Hispanic/Latinx adolescent ages 13-17 (n = 16,335). Analyses used weighted logistic regression models. Overall, 62.6% of parents of Hispanic/Latinx females and 46.4% of parents of Hispanic/Latinx males reported that they had received a provider recommendation for HPV vaccination. Among parents of females, receipt of a provider recommendation ranged from 55.0% among Central Americans to 73.3% among parents of Puerto Ricans. Among parents of males, the range was from 44.5% among Mexicans and multi-subgroup males to 53.4% among Cubans. There were no differences across Hispanic/Latinx subgroups in adjusted models among either males or females (all p > .05). Among parents of females, provider recommendation was less common among those whose preferred language was Spanish for Central Americans and South Americans (both p < .05). Efforts are needed to improve provider communication about and recommendations for HPV vaccination among the Hispanic/Latinx population and to ensure the availability of language assistance services for individuals with limited English proficiency.

Introductory Medical Spanish Elective: Creating and Evaluating a Case-Based Course Compatible with an 18-Month Pre-Clinical Medical Curriculum

BACKGROUND

Limited English proficiency patients experience high rates of medical errors and receive lower quality of care. To better prepare the healthcare workforce, Latino Medical Student Association (LMSA) members at Oregon Health & Science University (OHSU) developed an Introductory Medical Spanish course to complement an 18-month pre-clinical curriculum.

METHODS

This 10-week elective course consisted of 2 h of weekly instruction, two Cafecito cultural sessions, and one clinical standardized assessment (CSA). The authors used Bloom's taxonomy as a theoretical framework to design course components. Pre- and post-course surveys captured comfort scores with performing a history and physical (H&P) and building rapport in Spanish. Change in comfort was analyzed via paired T-test in STATA. The authors performed a content analysis of CSA feedback and a thematic analysis of Cafecito reflections.

RESULTS

Fifteen preclinical medical students in cohort 1 and sixteen in cohort 2 completed the 10-week course. Comfort scores significantly (p < 0.05) increased by 2.87 and 1 point(s) for cohorts 1 and 2, respectively. There were differences between cohorts 1 and 2, including self-reported language fluency (93% vs 47% "beginner" level) and value of the cultural sessions (73% vs 50%), respectively. Qualitative content analysis of CSA feedback and thematic analysis of Cafecito reflections revealed students successfully applied learned material to a new case and developed a newfound appreciation for Latinx public health issues.

CONCLUSIONS

This course effectively increased students' comfort using medical Spanish which successfully translated into simulated patient environments. It also provided a space to discuss nuances of health and Latinx cultures with peers. Ultimately, this course's feasible, effective structure can serve as a model to complement condensed pre-clinical undergraduate medical education (UME) curricula.

Bilingual and Bicultural Research Teams: Unpacking the Complexities

Researchers often describe use of “bilingual/bicultural” research teams, especially for research being conducted with marginalized communities. In this perspectives article, we argue that while increasing the diversity of research teams is imperative, using the term “bilingual/bicultural” without further explanation is problematic. We first review the nuances of the terms bilingual and bicultural individually. Next, we describe how the terms bilingual and bicultural cannot be conflated. Finally, we provide recommendations for researchers, journals, and funding agencies.

The Complexities of Assessing Language and Interpreter Preferences in Pediatrics

Providing patients, parents, and families high-quality healthcare in the language of their choice is a fundamental component of patient-centered care in pediatric settings. However, language needs may be complex and dynamic, creating clinical and ethical challenges in cases of provider–parent discordance regarding the need for an interpreter. In this perspectives article, we use a clinical encounter as a foundation to discuss the intricacies of addressing language needs in pediatrics. We also describe the urgent need for further innovation and improvement in linguistic supports available to diverse patients and families.

Satisfaction With Communication in Primary Care for Spanish-Speaking and English-Speaking Parents

BACKGROUND AND OBJECTIVE

Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents.

METHODS

Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English.

RESULTS

Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter.

CONCLUSIONS

Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

Rates and Predictors of Professional Interpreting Provision for Patients With Limited English Proficiency in the Emergency Department and Inpatient Ward

The provision of professional interpreting services in the hospital setting decreases communication errors of clinical significance and improves clinical outcomes. A retrospective audit was conducted at a tertiary referral adult hospital in Brisbane, Australia. Of 20 563 admissions of patients presenting to the hospital emergency department (ED) and admitted to a ward during 2013-2014, 582 (2.8%) were identified as requiring interpreting services. In all, 19.8% of admissions were provided professional interpreting services in the ED, and 26.1% were provided on the ward. Patients were more likely to receive interpreting services in the ED if they were younger, spoke an Asian language, or used sign language. On the wards, using sign language was associated with 3 times odds of being provided an interpreter compared with other languages spoken. Characteristics of patients including their age and type of language spoken influence the clinician's decision to engage a professional interpreter in both the ED and inpatient ward.

The "Battle" of Managing Language Barriers in Health Care

Providing safe and high-quality health care for children whose parents have limited English proficiency (LEP) remains challenging. Reports of parent perspectives on navigating language discordance in health care are limited. We analyzed portions of 48 interviews focused on language barriers from 2 qualitative interview studies of the pediatric health care experiences of LEP Latina mothers in 2 urban US cities. We found mothers experienced frustration with health care and reported suboptimal accommodation for language barriers. Six themes emerged relevant to health care across settings: the "battle" of managing language barriers, preference for bilingual providers, negative bias toward interpreted encounters, "getting by" with limited language skills, fear of being a burden, and stigma and discrimination experienced by LEP families. Parents' insights highlight reasons why effective language accommodation in health care remains challenging. Partnering with families to address the management of language barriers is needed to improve health care quality and safety for LEP patients and families.

Not just "getting by": factors influencing providers' choice of interpreters

BACKGROUND

Providers consistently underutilize professional interpreters in healthcare settings even when they perceive benefits to using professional interpreters and when professional interpreters are readily available. Little is known about providers' decision-making processes that shape their use of interpreters.

OBJECTIVE

To understand the variety of considerations and parameters that influence providers' decisions regarding interpreters.

DESIGN

A qualitative, semi-structured interview guide was used to explore providers' decision making about interpreter use. The author conducted 8 specialty-specific focus groups and 14 individual interviews, each lasting 60-90 minutes.

PARTICIPANTS

Thirty-nine healthcare professionals were recruited from five specialties (i.e., nursing, mental health, emergency medicine, oncology, and obstetrics-gynecology) in a large academic medical center characterized as having "excellent" interpreter services.

APPROACH

Audio-recorded interviews and focus groups were transcribed and analyzed using grounded theory to develop a theoretical framework for providers' decision-making processes.

KEY RESULTS

Four factors influence providers' choice of interpreters: (a) time constraints, (b) alliances of care, (c) therapeutic objectives, and (d) organizational-level considerations. The findings highlight (a) providers' calculated use of interpreters and interpreting modalities, (b) the complexity of the functions and impacts of time in providers' decision-making process, and (c) the importance of organizational structures and support for appropriate and effective interpreter utilization.

CONCLUSIONS

Providers actively engage in calculated use of professional interpreters, employing specific factors in their decision-making processes. Providers' understanding of time is complex and multidimensional, including concerns about disruptions to their schedules, overburdening others' workloads, and clinical urgency of patient condition, among others. When providers make specific choices due to time pressure, they are influenced by interpersonal, organizational, therapeutic, and ethical considerations. Organizational resources and guidelines need to be consistent with institutional policies and professional norms; otherwise, providers risk making flawed assessments about the effective and appropriate use of interpreters in bilingual health care.

Predictors of resident satisfaction in caring for limited English proficient families: a multisite study

OBJECTIVE

To assess residents' self-efficacy, satisfaction and frustration in the care of limited English proficient (LEP) families and to identify individual and programmatic factors associated with the above outcomes.

METHODS

A multisite cross-sectional survey of pediatric residents currently in training and caring for LEP families was conducted. Resident self-efficacy scores in specific skill domains were assessed. Clustered multivariate logistic regression analyses were used to identify individual and programmatic factors associated with increased satisfaction and frustration. Qualitative analyses were also utilized to identify themes related to frustrating aspects of care.

RESULTS

A total of 271 of 449 eligible residents representing 7 US pediatric residency programs participated in our study (60% response rate). A majority of residents (51%) rated their self-efficacy in the overall care of LEP families as low. Satisfaction was associated with a high self-efficacy score (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.8-12.6), increasing year in training (OR 3.2, 95% CI 1.01-10.2), frequent non-English language use (OR 3.1, 95% CI 1.1-8.8), and instruction on the use of interpreters (OR 1.9, 95% CI 1.02-3.64). Satisfaction was inversely associated with increased LEP patient volumes (OR 0.40, 95% CI 0.18-0.91). Clinical inefficiency related to interpreter use and distrust of interpreter skills were frequently cited as aspects that contribute to overall frustration.

CONCLUSIONS

A majority of residents reported lacking self-efficacy in their ability to deliver care to LEP patients, which may influence overall satisfaction with such encounters. Strategies that promote resident self-efficacy and assess non-English language proficiency should be included in future training curricula. Exposing trainees to best practices in interpreter-based encounters may further promote resident satisfaction.

Changes in language services use by US pediatricians

BACKGROUND AND OBJECTIVES

Access to appropriate language services is critical for ensuring patient safety and reducing the impact of language barriers. This study compared language services use by US pediatricians in 2004 and 2010 and examined variation in use in 2010 by pediatrician, practice, and state characteristics.

METHODS

We used data from 2 national surveys of pediatricians (2004: n = 698; 2010: n = 683). Analysis was limited to postresidency pediatricians with patients with limited English proficiency (LEP). Pediatricians reported use of ≥ 1 communication methods with LEP patients: bilingual family member, staff, physician, formal interpreter (professional, telephone), and primary-language written materials. Bivariate analyses examined 2004 to 2010 changes in methods used, and 2010 use by characteristics of pediatricians (age, sex, ethnicity), practices (type, location, patient demographics), and states (LEP population, Latino population growth, Medicaid/Children's Health Insurance Program language services reimbursement). Multivariate logistic regression was performed to determine adjusted odds of use of each method.

RESULTS

Most pediatricians reported using family members to communicate with LEP patients and families, but there was a decrease from 2004 to 2010 (69.6%, 57.1%, P < .01). A higher percentage of pediatricians reported formal interpreter use (professional and/or telephone) in 2010 (55.8%) than in 2004 (49.7%, P < .05); the increase was primarily attributable to increased telephone interpreter use (28.2%, 37.8%, P < .01). Pediatricians in states with reimbursement had twice the odds of formal interpreter use versus those in nonreimbursing states (odds ratio 2.34; 95% confidence interval 1.24-4.40).

CONCLUSIONS

US pediatricians' use of appropriate language services has only modestly improved since 2004. Expanding language services reimbursement may increase formal interpreter use.