Language: the ignored determinant of health

Canada is one of the most multicultural countries in the world, with growing numbers of families who do not speak English or French as a first language. However, providing language-concordant services for patients with non-official language preference (NOLP) is not a standardized or measured component of our healthcare system, reflecting the historical marginalization of minority groups in our society. Existing evidence from other countries demonstrates the importance of language as a social determinant of health, and illustrates improved healthcare outcomes for patients with NOLP with the use of medical interpretation. This commentary proposes that a change in our approach to patients with NOLP needs to be accomplished through concerted efforts at the policy, research, and institutional levels in healthcare.

Healthcare Provider Perceptions of the Use of Medical Interpretation in Primary Care

OBJECTIVES

Sixty-three percent of Latinos/as/x in Alabama, speak English "not well" or "not at all." Effective provider-patient communication is the foundation of successful clinical interactions. Medical interpretation is important to the healthcare provision for patients with limited English proficiency (LEP). We examined Alabama providers' perceptions of working with medical interpreters to identify strategies to improve healthcare provision for LEP patients.

METHODS

We conducted nine semistructured qualitative interviews with primary healthcare providers in western Alabama. We used NVivo to conduct thematic coding and content analysis.

RESULTS

Of the nine providers, one self-identified as Latina and the others identified as White. Four participants worked in community clinics and five worked at university-based clinics. Four themes emerged: preference for in-person interpreters over technology-based interpretation; providers' perceptions and expectations of the roles of professional interpreters; challenges in the communication process; and use of family members or other ad hoc interpreters.

CONCLUSIONS

To meet the needs of Latino/a/x communities, clinical settings should invest in adequate staffing of in-person interpreters, infrastructure and workflow improvements, and the hiring and training of polylingual providers. Capacity-building opportunities to establish team building between interpreters and providers could be useful tools in improving healthcare provision for LEP patients.

Strategies to Increase the Spanish-Speaking Workforce in Orthopaedic Surgery within the United States

ABSTRACT

Language-concordant care improves patient satisfaction. Given the increase in Spanish-speaking persons requiring orthopaedic care in the United States, it is essential to increase the Spanish-speaking workforce in orthopaedic surgery. We have proposed strategies to improve the proportion of Spanish-speaking orthopaedic surgeons in the U.S. through early exposure to orthopaedic surgery, by creating collaborative advancement and mentorship opportunities, by endorsing Spanish-language immersion opportunities, and by increasing workforce diversity awareness. Furthermore, we have suggested a strategy to better equip non-Spanish-speaking orthopaedic surgeons while caring for Spanish-speaking patients. Together, the suggested strategies offer a variety of approaches that can have a direct, tangible impact on optimizing orthopaedic care while enhancing patient-physician communication in the Spanish language.

Language Proficiency and Survival in Pancreatic Cancer: a Propensity Score-Matched Analysis

BACKGROUND

Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC.

METHODS

A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status.

RESULTS

Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation.

CONCLUSIONS

In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.

How do health professionals decide whether an interpreter is needed for families in neonatal and pediatric units?

OBJECTIVE

To examine how health professionals decide whether family members require an interpreter.

METHODS

69 health professionals, doctors, nurses, and allied health, from neonatal and pediatric units participated. Interviews used a verbal protocol analysis, which elicited their thoughts about using interpreters, including how they decided if an interpreter was needed.

RESULTS

Five themes captured the decision-making process health professionals use. Of these, three themes described the goals and beliefs participants brought to their interactions with family members: Ensuring understanding, Addressing socioemotional needs, and Who decides. The theme Assessing understanding was prominent within the interaction, while the final theme was Contextual factors influencing decision making. No differences were found between mono and multilingual participants, and few differences between health professional groups.

CONCLUSION

Health professionals find it difficult to assess whether a family member needs an interpreter and there is no consistency in how they make this decision, with some using heuristics and others a more systematic approach. Health professionals have beliefs about the purpose of an interpreter that potentially limit the voice of family members.

PRACTICE IMPLICATIONS

Health professionals need training to assist them in decisions about whether an interpreter is needed, including a decision tool and knowledge about policies.

Addressing Cultural Determinants of Health for Latino and Hmong Patients with Limited English Proficiency: Practical Strategies to Reduce Health Disparities

We explored how addressing culture may improve patient-provider relationships and reduce health disparities for racial and ethnic individuals with limited English proficiency (LEP). We analyzed qualitative data collected to explore health disparities in preventive cancer screenings for Hmong and Spanish-speaking LEP patients in a large Midwest healthcare system. We interviewed 20 participants (10 from each group) and the audiotaped interviews were transcribed verbatim, then back translated focusing on meaning. Data was analyzed using content analysis. Two themes are: conversation is relational and quality time is valued. Good communication skills involve the amount of conversation, clear explanations, and engaging with the patient. Quality of time meant physical time spent with patient and the task-oriented nature of the encounter. Cultural literacy in healthcare practice helps to understand the whole patient rather than focusing on the symptoms of illness. Patients should not be treated in isolation of their culture. A patient-centered approach to care means physicians should not remain culturally neutral but be more culturally sensitive. We propose steps to reduce disparities by increasing the awareness of cultural literacy for physicians to improve patient-provider relationship.

The Impact of Professional Language Interpreting in Midwifery Care: A Review of the Evidence

BACKGROUND: Patients’ limited proficiency in the language of health care providers is known to be associated with health care disparities. Reluctance to use professional interpreting is documented across a wide range of health care professionals. Most of the literature on the effect of interpreting practices has focused on non-midwifery contexts.

OBJECTIVE: To review the evidence regarding how using professional interpreters impacts the midwifery care of women with limited dominant language proficiency (LDLP).

METHODS: Eligible studies were identified using searches of MEDLINE, CINAHL, and Maternity and Infant Care, then analyzed and assessed for applicability to midwifery.

RESULTS: 40 eligible papers, and two systematic reviews containing 48 additional papers, were included. The use of professional interpreters was found to support all aspects of the midwife’s direct role, with some complex findings on woman-centered communication during interpreted encounters. The use of ad hoc interpreters, or no interpreting, undermines all aspects of midwifery care for women with LDLP.

IMPLICATIONS: Midwifery care should be enhanced by increasing midwives’ use of professional interpreters; future research should consider how best to achieve this or investigate the comparative efficacy of more complex interventions, such as interpreter-doulas.