Cascades East AHEC - Area Health Education Center, Central and Southeastern Oregon

A growing body of research on health disparities between ethnic groups is making increasingly clear the case that being a member of a minority group in the United States, in and of itself, can be a barrier to health care. And though socioeconomic status and ethnicity are only two elements in the larger picture of access to care, statistically they have shown themselves to be critically important. The inability to speak English, in particular, has been empirically associated with less care-seeking and diminished access.

Most health care professionals enter their careers with the desire to cure or heal. For this reason, we can assume that non-financial barriers to care are erected unconsciously and unintentionally. It is the hope of this initiative that with adequate research, training and resources, the tide of U.S. health care can be turned to work more effectively with LEP populations.

Problems Created by Language Barriers

Though it seems there is much to learn about language barriers and interpreting, one thing we are able to describe is how language barriers seem to be creating problems for both patients and for providers, based on the literature.

Problems for Patients

Language and communication influence how and if NEP/LEP patients access and experience health care. Because of language barriers, NEP/LEP patients often encounter the following basic types of problems:

Lack of awareness of existing services and how to access them.
Difficulty in making appointments and accessing basic information about the visit, when they do seek care.
Inability to communicate adequately with health care support staff, providers, and ancillary staff at all points within the healthcare delivery system.
Low patient satisfaction with cross-language encounters, which may lead to reluctance to return to the health care setting.

Furthermore, research shows that even when NEP/LEP patients are able to access health care, health care quality may be diminished and health outcomes may be poorer for them than for other patients. Specifically:

NEP/LEP patients receive less information about the therapeutic regimen, and understand less of the instructions related to medication.¹
After cross-language encounters, patients are less likely to keep subsequent appointments and are more likely to make emergency room visits than are patients in same-language encounters.²
Non-English speakers are less likely to receive preventive services.³
Latino parents, in one study, cited language barriers as the cause of misdiagnoses, poor medical care and inappropriate medications and /or hospitalizations of their children.⁴

Problems for Providers

Because of language barriers, providers often encounter difficulties:

In making an accurate diagnosis.
In meeting informed consent responsibilities.
While explaining care options to NEP/LEP patients. (This may lead to more limited options for caring for the patient).
During health education efforts.
In convincing NEP/LEP patients to comply with a treatment regimen they may not understand.

Background

Though language barriers have long been a concern for health professionals and patients in this country, the debate over what qualifies as adequate supplementary language services for LEP and NEP patients and how to pay for these services has been especially heated in the last year. This debate gathered steam after the release of the Office of Civil Right's policy guidance on Aug. 30, 2000, which clarified the existing policies of the Department of Health and Human Services for LEP populations. The guidance makes clear requirements⁵ to which health care providers (and others) who receive federal funds must adhere in order to continue receiving federal funding.

The Civil Rights Act of 1964 states that "No person in the United States shall on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance."⁶ Culture and language have typically been considered an essential part of "national origin."⁷ As such, many key players in the health care environment have sought to address this issue, though few have done so as thoroughly as the recent OCR guidance. For instance:

State and Federal laws require healthcare providers and managed care organizations to have medical interpreters for NEP/LEP patients but typically do not define what constitutes adequate training or proficiency for interpreters.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has also adopted accreditation standards for hospitals, consistent with the intent of federal regulations. Some of these standards include: Meeting access and learning needs of NEP/LEP populations, establishing processes to determine cultural implications to proper care, providing understandable written copies of rights, and obtaining informed consent.

The OCR guidance be distilled into four key mandates⁸:

Assessment. The recipient/covered entity conducts a thorough assessment of the language needs of the population to be served;
Development of Comprehensive Written Policy on Language Access. The recipient covered entity develops and implements a comprehensive written policy that will ensure meaningful communication;
Training of Staff. The recipient/covered entity takes steps to ensure that staff understands the policy and is capable of carrying it out; and
Vigilant Monitoring. The recipient/covered entity conducts regular oversight of the language assistance program to ensure that LEP persons meaningfully access the program.

The central issue of the debate following the OCR guidance has been that, despite a fairly broad sense in the health care community that NEP and LEP populations indeed have a right to the services of a medical interpreter, these services can add significant cost to care; a cost that is not currently addressed by federal funding.

Furthermore, there is little consensus around what constitutes adequate training for a medical interpreter, and not much is known empirically about the effectiveness of interpreter services.

Shapiro J and Saltzer E (1981). Cross-cultural aspects of physician-patient communication patterns. Urban Health. Vol 10, 10-15
Manson A. (1988). Language concordance as a determinant of patient compliance and emergency room visits in patients with asthma. Medical Care. Vol. 26. 1119-1128
Woloshin S, Schwartz LM, Katz SJ, and Welch HG. (1997). Is language a barrier to the use of preventive services? Journal of General Internal Medicine. Vol. 12, 472-477.
Flores G, Abreau M, Olivar M, and Kastner B. (1998). Access barriers to health care for Latino children. Archives of Pediatric and Adolescent Medicine. Vol. 152, 119-1125.
http://www.hhs.gov/ocr/lep/guide.html
Section 601 of Title VI of the Civil Rights Act of 1964, 42 U.S.C. Section 2000d et. seq.
Woloshin S, Bickell NA, Schwartz LM, Gany F and Welch HG. (1995). Language Barriers in Medicine in the United States. Journal of the American Medical Association. Vol. 273 (9), 724-728.
http://www.hhs.gov/ocr/lep/guide.html

The preceeding information has been developed by The Robert Wood Johnson Foundation’s Hablamos Juntos Program. It is also available on their website at www.hablamosjuntos.org. The RWJ Hablamos Juntos Program is located at the Tomás Rivera Policy Institute at Claremont College in Claremont, CA.