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Hospital leaders across America are changing their procedures in order to increase the quality of care they provide to their patients. While quality for all patients needs to improve, research shows that patients of different ethnicities may receive different levels of care. This can be caused by many factors, including whether or not patients and providers are communicating effectively. Although U.S. hospitals are required to provide language services to patients who speak limited English, there are no guidelines on the most effective ways to communicate with these patients.

In order to improve quality of care and reduce racial and ethnic disparities, more hospitals are recognizing that the quality of language services that they provide is directly linked to the quality of medical care their patients receive.

Many studies and projects have provided information about the characteristics of a high-quality language services program in a health care system. What remains a challenge, however, is the development of an appropriate set of administrative and organizational mechanisms to embed language services into the very fabric of health care delivery. Speaking Together: National Language Services Network aims to address this challenge, recognizing that in order to more effectively use the limited resources of hospital-based language services, institutions need to better understand how to move linguistic competence into the mainstream of service delivery and quality improvement activities.

Background

In 1999, Congress requested that the Institutes of Medicine (IOM) conduct a study to examine the extent of health care disparities among racial and ethnic minorities in America. The study, titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, determined that gaps in the quality of health care for minorities exist even when factors such as income and insurance status are comparable to Caucasians. One of these gaps lies in the quality of patient-provider communication.

More than 46 million people, or approximately 17 percent of the U.S. population, speak a language other than English in their homes,1 a number that is expected to increase in the coming decades. For this growing portion of the population, poor communication can result in serious consequences when it comes to accessing health care. Persons with limited English proficiency (LEP) are less likely to have a regular source of primary care2 and are less likely to receive preventive services than persons whose primary language is English.3 In a national survey of insured non-elderly adults, for example, Spanish-speaking Hispanic patients showed significantly lower use compared to non-Hispanic white patients for physician or mental health visits, influenza vaccination and mammograms.4

Communication barriers due to LEP can also adversely affect quality of care delivered to patients. Such barriers impair discussions of symptoms and alternative treatment regimens, resulting in misdiagnoses or poor treatment decisions. Communication barriers also impede the understanding and compliance of treatment plans and therapies among patients with LEP.5 For example, studies have shown that patients who need an interpreter, but do not receive one, are less likely to understand the instructions for taking medications, receive information on medication side effects, and experience satisfaction with their care.6, 7 One survey found that in the absence of an interpreter, Spanish-speaking, LEP patients report significant difficulty in being able to fully explain their symptoms and trust the medical recommendations of an English-speaking only provider.8

Moreover, barriers due to LEP slow the efficiency of health care delivery. In a study of health care utilization in an emergency department (ED) setting, patients with LEP demonstrated a higher rate of resource utilization and increased ED visit times compared to those proficient in English.9

Medical interpreters, when assessed and trained, can help in bridging this critical communication gap between provider and LEP patient. For this reason, the IOM lists supporting the use of interpreter services as a chief strategy for fighting disparities in health care and recommends that professional interpretation services be “the standard where language discordance poses a barrier to care.”10 Unfortunately, providers in communities with rapid rates of growth among non-English speaking patient populations often do not have the knowledge or tools to enable them to design, develop and grow sufficient language service capacity in response to the needs of their linguistically diverse patient populations.

1. U.S. Bureau of the Census, Profile of Selected Social Characteristics: 2000 (Table DP-2), available at http://factfinder.census.gov.
2. Weinick RM, Krauss NA. Racial/Ethnic differences in access to care. Amer Jour Public Health 2000; 90(11):1771-1774.
3. Woloshin S, Schwarts LM, Katz SJ, Welsh HG. Is language a barrier to the use of preventive services? J Gen Intern Med 1997;12:472-477.
4. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured. Med Care 2001;40:52--9.
5. Ku, L. How race/ethnicity, immigration status and language affect health insurance coverage, access to care and quality of care among the low-income population. Washington, DC: Kaiser Family Foundation, August 2003.
6. Andrulis, D, Goodman N, Pryor N. What a difference an interpreter can make: Health care experiences of uninsured with limited English proficiency. Boston, MA: The Access Project, April 2003.
7. David RA, Rhee B. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. Mt Sinai J Med, 1998; 65(5,6): 393-397
8. Wirthlin Worldwide. Hablamos Juntos: We Speak Together, 2001. www.hablamosjuntos.org.
9. Hampers, LC. Language barriers and resource utilization in a pediatric emergency department. Pediatrics, 1999; 103(6): 1253-1256.
10. Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” (Washington: 2003), National Academies Press.

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