The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond

Over the past few decades, the number and diversity of limited English speakers in the USA has burgeoned. With this increased diversity has come increased pressure—including new legal requirements—on healthcare systems and clinicians to ensure equal treatment of limited English speakers. Healthcare providers are often unclear about their legal obligations to provide language services. In this article, we describe the federal mandates for language rights in health care, provide a broad overview of existing state laws and describe recent legal developments in addressing language barriers. We conclude with an analysis of key policy initiatives that would substantively improve health care for LEP patients.     

Linguistic disparities in health care access and health status among older adults

BACKGROUND: English proficiency may be important in explaining disparities in health and health care access among older adults. SUBJECTS: Population-based representative sample (N=18,659) of adults age 55 and older from the 2001 California Health Interview Survey. METHODS: We examined whether health care access and health status vary among older adults who have limited English proficiency (LEP), who are proficient in English but also speak another language at home (EP), and who speak English only (EO). Weighted bivariate and multivariate survey logit analyses were conducted to examine the role of language ability on 2 aspects of access to care (not having a usual source of care, delays in getting care) and 2 indicators of health status (self-rated general health and emotional health). RESULTS: Limited-English proficient adults were significantly worse off (1.68 to 2.49 times higher risk) than EO older adults in 3 of our 4 measures of access to care and health status. Limited-English proficient older adults had significantly worse access to care and health status than EP older adults except delays in care. English proficient adults had 52% increased risk of reporting poorer emotional health compared with EO speakers. CONCLUSIONS: Provision of language assistance services to patients and training of providers in cultural competence are 2 means by which health care systems could reduce linguistic barriers, improve access to care, and ultimately improve health status for these vulnerable populations.     

Navigating language barriers under difficult circumstances

The proportion of the U.S. population with limited English proficiency is growing. Physicians often find themselves caring for patients with limited English proficiency in settings with limited language services. There has been little exploration of the decisions physicians face when providing care across language barriers. The authors offer a conceptual framework to aid physicians in thinking through difficult choices about language services and provide responses to common questions encountered in the care of patients with limited English proficiency. Specifically, they describe 4 factors that should inform the decision to call an interpreter (the clinical situation, degree of language gap, available resources, and patient preference), discuss who may be an appropriate interpreter, and offer strategies for when a professional interpreter is not available. The authors use a hypothetical case to illustrate how decisions about language services may evolve over the course of an interaction. This conceptual and practical approach can help clinicians to improve the quality of care provided to patients with limited English proficiency.     

Mail‐delivered arthritis self‐management tool kit: A randomized trial and longitudinal followup

Objective

To determine the effectiveness of an intervention Tool Kit of arthritis self‐management materials to be sent once through the mail, and to describe the populations reached.

Methods

Spanish speakers (n = 335), non‐Hispanic English‐speaking African Americans (n = 156), and other non‐Hispanic English speakers (n = 404) were recruited separately and randomized within each of the 3 ethnic/racial categories to immediately receive the intervention Tool Kit (n = 458) or to a 4‐month wait‐list control status (n = 463). At the end of 4 months, controls were sent the Tool Kit. All subjects were followed in a longitudinal study for 9 months. Self‐administered measures included health status, health behavior, arthritis self‐efficacy, medical care utilization, and demographic variables. Using analyses of covariance and t‐tests, analyses were conducted for all participants and for Spanish‐ and English‐language groups.

Results

At 4 months, comparing all intervention subjects with randomized wait‐list controls, there were significant (P < 0.01) benefits in all outcomes except medical care utilization and self‐rated health. The results were maintained at 9 months compared with baseline. On average, the Tool Kit reached persons ages 50–56 years with 12–15 years of schooling. There were few differences between English‐ and Spanish‐language participants in either the effectiveness or reach variables.

Conclusion

A mailed Arthritis Self‐Management Tool Kit proved effective in improving health status, health behavior, and self‐efficacy variables for up to 9 months. It also reached younger persons in both English‐ and Spanish‐language groups and Spanish speakers with higher education levels than previous studies of the small‐group Arthritis Self‐Management Program.     

Is language a barrier to the use of preventive services?

Objective

To isolate the effect of spoken language from financial barriers to care, we examined the relation of language to use of preventive services in a system with universal access.

Design

Cross-sectional survey.

Setting

Household population of women living in Ontario, Canada, in 1990.

Participants

Subjects were 22,448 women completing the 1990 Ontario Health Survey, a population-based random sample of households.

Measurements and Main Results

We defined language as the language spoken in the home and assessed self-reported receipt of breast examination, mammogram and Pap testing. We used logistic regression to calculate odds ratios for each service adjusting for potential sources of confounding: socioeconomic characteristics, contact with the health care system, and measures reflecting culture. Ten percent of the women spoke a non-English language at home (4% French. 6% other). After adjustment, compared with English speakers, French-speaking women were significantly less likely to receive breast exams or mammography, and other language speakers were less likely to receive Pap testing.

Conclusions

Women whose main spoken language was not English were less likely to receive important preventive services. Improving communication with patients with limited English may enhance participation in screening programs.     

How Will the U.S. Healthcare System Meet the Challenge of the Ethnogeriatric Imperative?

Much of the geriatric imperative that is facing providers in the United States is an ethnogeriatric imperative, because one-third of older Americans are projected to be from one of the minority populations by mid-century, and that vastly underrepresents the actual diversity providers will see. Because of the vast heterogeneity of culture, language, health beliefs, risk for disease, and other factors, it is important for policy makers and health providers to be familiar with the diverse characteristics and needs of the various groups that will need geriatric care if they are to receive effective services. Challenges to high-quality ethnogeriatric care include disparities in health status and health care, differences of acculturation level and other characteristics within the populations, language and limited English proficiency, health literacy, culturally defined health beliefs and syndromes, and specific beliefs and preferences about long-term and end-of-life care. Some models of successful ethnogeriatric care have been identified and have in common the involvement of members of the target population in the development and design of the services and the use of cultural liaisons from the ethnic community being served, such as community health workers, or promatores . Thirteen recommendations are suggested for policy and practice changes in multiethnic and ethnic-specific health programs to provide competent ethnogeriatric care in the U.S. healthcare system.     

Impact of language barriers on patient satisfaction in an emergency department

OBJECTIVE: To examine patient satisfaction and willingness to return to an emergency department (ED) among non-English speakers. DESIGN: Cross-sectional survey and follow-up interviews 10 days after ED visit. SETTING: Five urban teaching hospital EDs in the Northeastern United States. PATIENTS: We surveyed 2,333 patients who presented to the ED with one of six chief complaints. MEASUREMENTS AND MAIN RESULTS: Patient satisfaction, willingness to return to the same ED if emergency care was needed, and patient-reported problems with care were measured. Three hundred fifty-four (15%) of the patients reported English was not their primary language. Using an overall measure of patient satisfaction, only 52% of non-English-speaking patients were satisfied as compared with 71% of English speakers (p < .01). Among non-English speakers, 14% said they would not return to the same ED if they had another problem requiring emergency care as compared with 9.5% of English speakers (p < .05). In multivariate analysis adjusting for hospital site, age, gender, race/ethnicity, education, income, chief complaint, urgency, insurance status, Medicaid status, ED as the patient's principal source of care, and presence of a regular provider of care, non-English speakers were significantly less likely to be satisfied (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.39, 0.90) and significantly less willing to return to the same ED (OR 0.57; 95% CI 0.34, 0.95). Non-English speakers also were significantly more likely to report overall problems with care (OR 1.70; 95% CI 1.05, 2.74), communication (OR 1.71; 95% CI 1.18, 2.47), and testing (OR 1.77; 95% CI 1.19, 2.64). CONCLUSIONS: Non-English speakers were less satisfied with their care in the ED, less willing to return to the same ED if they had a problem they felt required emergency care, and reported more problems with emergency care. Strategies to improve satisfaction among this group of patients may include appropriate use of professional interpreters and increasing the language concordance between patients and providers.     

Impact of english language proficiency on receipt of pap smears among hispanics

Our aim was to assess the impact of English language proficiency on Pap smear use among Hispanics. We performed a cross-sectional study using 2000 National Health Interview Survey data and included 2,331 Hispanic women, age ≥18 without a hysterectomy. After adjusting for sociodemographic and access factors, highly proficient English speakers were more likely to report a Pap smear in the past 3 years as compared to low proficient (adjusted prevalence ratio, 1.16; 95% confidence interval, 1.08 to 1.22). Also associated with Pap smear use were income, usual source of care, and health insurance. Our finding suggests that low English language proficiency is a barrier to receiving recent Pap smears among Hispanics. Supported by a grant from the American Cancer Society (CCCDA-03-197-01-CCCDA).     

Limited English Proficiency in Older Adults Referred to the Cardiovascular Team

Limited English proficiency (LEP) is defined as individuals in whom English is not the primary language and who have limited ability to read, speak, write, or understand the English language. Cardiovascular (CV) team members routinely encounter language barriers in their practice. These barriers have a significant impact on the quality of CV care that patients with LEP receive. Despite evidence demonstrating the negative association between language barriers and health disparities, the impact on CV care is insufficiently known. In addition, older adults with CV disease and LEP are facing increasing risk of adverse events when complex medical information is not optimally delivered. Overcoming language barriers in CV care will need a thoughtful approach. Although well recognized, the initial step will be to continue to highlight the importance of language needs identification and appropriate use of professional interpreter services. In parallel, a health system-level approach is essential that describes initiatives and key policies to ensure a high-level quality of care for a growing LEP population. This review aims to present the topic of LEP during the CV care of older adults, for continued awareness along with practical considerations for clinical use and directions for future research.     

Health plan effects on patient assessments of medicaid managed care among racial/ethnic minorities

OBJECTIVE: To examine the extent to which racial/ethnic differences in Consumer Assessment of Health Plans Study (CAHPS) ratings and reports of Medicaid managed care can be attributed to differential treatment by the same health plans (within-plan differences) as opposed to racial/ethnic minorities being disproportionately enrolled in plans with lower quality of care (between-plan differences). DESIGN: Data are from the National CAHPS Benchmarking Database (NCBD) 3.0. Data were analyzed using linear regression models to determine the overall effects, within-plan effects, and between-plan effects of race/ethnicity and language on patient assessments of care. Standard errors were adjusted for nonresponse weights and the clustered nature of the data. PATIENTS/PARTICIPANTS: A total of 49,327 adults enrolled in Medicaid managed care plans in 14 states from 1999 to 2000. MAIN RESULTS: Non-English speakers reported worse experiences compared to those of whites, while Asian non-English speakers had the lowest scores for most reports and ratings of care. An analysis of between-plan effects showed that African Americans, Hispanic-Spanish speakers, American Indian/Whites, and White-Other language were more likely than White-English speakers to be clustered in worse plans as rated by consumers. However, the majority of the observed racial/ethnic differences in CAHPS reports and ratings of care are attributable to within-plan effects. The ratio of between to within variance of racial/ethnic effects ranged from 0.07 (provider communication) to 0.42 (health plan rating). CONCLUSIONS: The observed racial/ethnic differences in CAHPS ratings and reports of care are more a result of different experiences with care for people enrolled in the same plans than a result of racial/ethnic minorities being enrolled in plans with worse experiences. Health care organizations should engage in quality improvement activities to address the observed racial/ethnic disparities in assessments of care.     

Effect of awareness of language law on language access in the health care setting

BACKGROUND: Federal law obligates health care providers receiving federal funding to ensure language access to limited English-proficient (LEP) individuals who cannot communicate with their provider. OBJECTIVE: To determine whether LEP individual awareness of this law improved language access through interpreter utilization. DESIGN, SETTING, AND PARTICIPANTS: In June 2003, a telephone survey of 1,200 Californians was conducted in 11 non-English languages. MEASUREMENTS: The survey included items on English proficiency, awareness of language law, health care utilization, and communication methods. Language access was defined as having a provider who speaks the individual's language (language-concordant) or utilizing an interpreter. RESULTS: There were 1,000 LEP participants, of whom 371 (37%) were aware of the language law. Four hundred and ninety-one (49%) of LEP participants had a language-concordant provider. Of the remaining 509 LEP participants without a language-concordant provider, 111 (22%) reported interpreter utilization in the health care setting. After controlling for age, gender, education, income, insurance status, years in the United States, health care utilization, and level of English proficiency, awareness of law was not associated with interpreter utilization (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.38, 1.17; P=.16), but was associated with having a language-concordant provider (OR 1.64; 95% CI 1.19, 2.26; P=.003). CONCLUSION: Awareness of language law is not sufficient to resolve language barriers for LEP individuals. Provider and organization level barriers to language access must be addressed.     

Vulnerability of older Latino and Asian immigrants with limited English proficiency

OBJECTIVES: To explore the implications of limited English proficiency (LEP) for disparities in health status and healthcare service use of older Latino and Asian immigrants. DESIGN: Cross‐sectional analysis of existing secondary data. SETTING: The 2007 California Health Interview Survey. PARTICIPANTS: Latino and Asian immigrants aged 60 and older (n=1,745) were divided into three language proficiency groups: older adults who have LEP, are proficient in English but also speak another language at home (EP), and speak English only (EO). MEASUREMENTS: Sociodemographic characteristics, health status, health service use, and barriers to service use were compared. RESULTS: Older Latino and Asian immigrants with LEP tended to have poorer self‐rated health and higher psychological distress than the EP and EO groups. They were also less likely than the EP and EO groups to use health services and more likely to experience barriers to service use (e.g., difficulty understanding written information at the doctor's office). CONCLUSION: Older Latinos and Asians with LEP are at higher risk for poor physical and mental health outcomes and inadequate health care. Healthcare systems should consider strategies to address the language needs of older immigrants to reduce the effect of linguistic disparities on access to care and ultimately to improve health status for these vulnerable populations.     

Family Perceptions of the Usual Source of Care among Children with Asthma by Race/Ethnicity, Language, and Family Income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.     

Family Perceptions of the Usual Source of Care among Children with Asthma by Race/Ethnicity,Language, and Family Income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996–2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.     

Are latinos less satisfied with communication by health care providers?

OBJECTIVE: To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white). METHODS: A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale. MAIN RESULTS: We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this "very poor," "poor," or "fair"; p <.01); (2) answers to their questions (27% vs 16% vs 12%; p <.01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p <.01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p <.01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p <.01). CONCLUSION: This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.     

Language Barriers,Physician-Patient Language Concordance,and Glycemic Control Among Insured Latinos with Diabetes: The Diabetes Study of Northern California (DISTANCE)

BACKGROUND  

A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown.