A Spanish-speaking patient is complaining of being “intoxicado”. The non-Spanish speaking paramedics translate it as being intoxicated, while the intended meaning was “nauseated”. The patient is admitted to the hospital for a drug overdose. After being treated for this diagnosis for 36 hours, the patient is finally reassessed and diagnosed with intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery.
This is just one of many real-life tragic cases that can happen due to a language barrier between a patient and their healthcare team.
About 68 million people in the United States speak another language than English at home. Hundreds of languages are spoken or signed in the U.S., making it one of the most linguistically diverse countries in the world. This diversity comes with its challenges and opportunities. Unfortunately, it can create language barriers in healthcare leading to health disparities and impacting health equity. Research shows that these language barriers, and limited health literacy, can ultimately lead to poorer health outcomes including increased hospitalization rates and even higher mortality rates.
In this article, we’ll discuss different types of language barriers in healthcare, their impacts on health outcomes, and how healthcare organizations can address them effectively.
In this article, we discuss:
Examples of language barriers in healthcare
Navigating healthcare in the U.S. can be challenging for many people due to communication barriers. Some of these communication barriers are language barriers which can present themselves in different forms.
Different languages
One of the most obvious language barriers is when the patient and their providers don’t speak the same language. As mentioned earlier, the U.S. population is very diverse and it’s estimated that 25 million or eight percent of people ages five or older have limited English proficiency (LEP). The Department of Health and Human Services identifies people with LEP as those whose English is not their primary language and who have a limited ability to read, write, speak, or understand English.
LEP makes it challenging for patients to engage in their treatments, determine the risks and benefits of proposed treatments, and give informed consent.
For providers, when selecting a form of translation service, it’s important to assess the complexity of English required in the clinical interaction. They also have to determine if the patient can make a decision. Another challenge for interaction between providers and LEP patients is the clinical setting: is it a busy office or hospital? Is the patient acutely unwell? How to record the interaction? How do we ensure that there is no breach of confidentiality?
Health literacy
Even when a patient is perfectly fluent in English, another language barrier can be a low level of health literacy.
An individual’s health literacy is the degree to which a person can find, understand, and use health information and services to inform health-related decisions and actions for themselves and others. According to the National Assessment of Adult Literacy, only 12% of adults in America have proficient health literacy skills. In other words, the majority of adults in the U.S. don’t have adequate health literacy to effectively navigate the healthcare system.
Individuals with low health literacy are more likely to return incomplete medical assessment forms, miss doctor appointments, or postpone communication with their providers. They also have more difficulty reading and understanding medication labels.
English proficiency
English proficiency can also be a language barrier for many non-English speaking patients.
According to the U.S. Department of Education, about half of U.S. adults have low English literacy. The average reading level of Americans is 8th grade. An estimated 45 million Americans are considered functionally illiterate and can’t read above a 5th-grade level. Fifty percent of U.S. adults can’t read a book written at an 8th-grade reading level. Yet most patient education material is written at a high school or college reading level.
As a result, there’s a gap in understanding between healthcare providers and patients. Physicians tend to overestimate patients’ literacy skills, and patients tend to overestimate their understanding and fail to recall important medical information.
Language barriers for visually impaired and deaf patients
Two groups of individuals who are particularly affected by language barriers are visually impaired and hard of hearing patients.
Deaf people often lack access to crucial information regarding their health and clear communication in the healthcare system. As a result, they tend to have low health literacy compared to hearing people. Deaf sign language users often report low satisfaction regarding their physician-patient communications and better access to health care in the emergency department than with their primary care physicians.
Individuals with visual impairment often face similar situations. In the U.S., 20 million individuals live with visual impairment. Since they depend on auditory and tactile communication mediums, these individuals have limited exposure to medical and healthcare information that is typically first available for sighted people. Research suggests that people with visual impairment and low health literacy are less likely to follow health care recommendations and to understand disease progression.
Health Disparities and Language Barriers
Research shows that language barriers in healthcare lead to health inequities, such as lower quality of healthcare delivery and patient safety. These associated health inequalities also ultimately lead to poorer health outcomes.
Less access to healthcare services
Patients who don’t speak the local language often have less access to healthcare services and face poorer health outcomes than patients speaking the language. For instance, for patients with low language proficiency, it may be challenging to set up follow-up appointments, refill prescriptions, and adhere to medical instructions, which can lead to poor treatment adherence and poor disease management. It can have dire consequences, especially when patients have to self-manage their conditions at home with sensitive medications such as insulin.
Worse health outcomes
Over time, language barriers can lead to elevated risk of adverse events, delayed access to timely healthcare, suboptimal care, dissatisfaction with care received, and poor health outcomes. Although the presence of medical interpreters can help bridge these gaps, that intervention alone may not be enough to address health inequity resulting from language barriers.
Increased risk of death
Limited health literacy has also been linked to increased hospitalization rates, chronic disease, and higher mortality rates.
One study from the Archives of Internal Medicine studied the impact of health literacy in older Medicare enrollees. It found that mortality rates for patients with adequate, marginal, and inadequate health literacy were 18.9%, 28.7%, and 39.4%, respectively (P < .001). The hazard ratios for all-cause mortality were 1.52 (95% confidence interval, 1.26-1.83) and 1.13 (95% confidence interval, 0.90-1.41) for enrollees with inadequate and marginal health literacy, respectively, compared with those with adequate health literacy. In other words, patients with inadequate and marginal health literacy were more likely to die than those with adequate health literacy.
Another study from the Journal of the American Heart Association looked at the link between health literacy and post-hospitalization mortality for patients with acute heart failure. Researchers found that low health literacy was associated with an increased risk of death. The adjusted hazard ratio for death in patients with low health literacy was 1.32 (95% CI 1.05, 1.66, P=0.02) compared to patients with higher health literacy.
Positive impact of effective communication in healthcare
There has been a lot of research these past few years about interventions to bridge communication gaps. And data has shown that effective communication in healthcare can improve health outcomes.
Quality communication between providers and patients has been shown to increase patient-centered health outcomes such as patient well-being, patient satisfaction, and patient adherence to providers' recommendations.
In one systematic review, researchers found that health literacy interventions improved the level of glycemic control and patient self-management skills in type 2 diabetes.
One study about health literacy strategies for patients with uncontrolled hypertension found that the interventions resulted in a significant blood pressure decrease at twelve months for patients with lower and higher health literacy. These multilevel interventions included regular training and education for the clinical teams, education materials mailed to the patients, and phone coaching sessions.
Interventions to improve health literacy in patients with chronic diseases may have a positive impact on patient health status, depression and anxiety, and patient self-efficacy.
Interventions combining different strategies such as provider communication training, healthcare navigation support, patient education, and caregiver support, seem to have the greatest impact on health outcomes. These combined interventions can bridge different gaps for patients with lower health literacy such as access and utilization of health care, provider-patient interaction, and self-care.
For patients with LEP, effective communication through professional interpreter services can decrease communication errors, improve clinical outcomes, and increase satisfaction with communication and clinical services.
Effective communication can even decrease the rate of readmission for patients with LEP and lower hospital expenses. At one hospital, clinical teams observed a reduction in 30-day admissions from 17.8% to 13.4% after installing an interpreter telephone at patient bedsides. During the eight months of the intervention, the avoided admissions saved the hospital an estimated $161,404 (after accounting for the interpreter's costs).
This data shows that language barriers can be addressed by assessing patient understanding of medical and healthcare information, using patient-friendly language, communicating in the language that the patient is proficient with, and educating practitioners and clinicians.
How Arine Addresses Language Barrier Issues to Improve Health Equity
Breaking down language barriers in healthcare requires multilevel interventions that can be challenging and time-consuming to implement.
Arine’s artificial intelligence-powered platform can enable the timely implementation of powerful interventions to support health organizations in addressing language barriers. The platform offers both workflow processes to support this as well provides automated tools to enable care teams.
The first step to addressing potential language barriers is to be able to capture that information and ensure that it is not only shared across care teams but is used to tailor workflows. The Arine platform can integrate data fields which include race, ethnicity, and language preferences for both written and spoken languages. Too often when a patient speaks a language fluently it is assumed the patient can read and write in that language as well. This is a dangerous assumption that puts a patient at risk by relying on them to remember the verbal conversation that occurred. In addition, users of the platform can collect information regarding patient health literacy and health educational background within structured questionnaires included in the platform, or through clinical notes which are accessible across the care team.
To have the greatest impact with interventions, linguistic or cultural matching of patients to care team members can have additional benefits, and the Arine platform’s workflows can be configured to ensure that tasks and interventions are assigned to appropriate care team members. Perhaps the most overlooked barrier is the one in which the people on opposite ends of the conversation speak the same language, but do not share the same context. It is one thing to speak to a patient in Spanish, it is another thing altogether to know the Spanish-speaking patient is likely eating beans and rice or seeking “care” from a curandero. Decoding the cultural and contextual background, as well as speaking the language is vital in connecting with patients and building the trust necessary to motivate the desired change in behavior.
Finally, educational materials shared with patients must be designed to meet the needs of any engaged population. In the Arine platform, personalized care plans have been carefully designed for accessibility, having been written at the 4th-grade reading level. This helps drive increased patient adherence to recommendations and patient satisfaction.
For example, Arine worked with one client, a large non-profit Medicare Advantage plan serving members across western and southwestern states, to reduce racial and ethnic disparities in their patient medication adherence. At the program’s onset, the plan’s medication adherence scores were lower for their Black and Hispanic members compared to their general population.
The health plan understood that in addition to other challenges, several language barriers impacted the medication adherence of their Black and Hispanic members:
- These members had limited English proficiency.
- They trusted nurses more than physicians.
- They didn’t understand what their prescribed medications were or how they would help improve their conditions.
To address these barriers, Arine’s client recognized that they needed to improve their outreach strategies by training more staff on cultural competence and pairing their members with staff that were culturally and linguistically matched.
Using Arine’s platform, their care team was able to:
- Identify members who were underutilizing care through carefully designed member selection algorithms.
- Ask culturally sensitive Smart Questions to better inform interventions
- Use automated workflow engines to pair patients with the best team members based on language and culture.
- Direct members to lower-cost treatment options, or the plan’s resources in the community, as required.
As a result, Arine’s client exceeded their first-year goal and reduced the medication adherence disparity seen in their Black and Hispanic populations by 35%. The adherence for historically non-adherent members also significantly increased, from 50-62% proportion of days covered (PDC) in diabetes and statins to >80% PDC.
Conclusion
Language barriers can have devastating effects at the patient level and negatively impact health equity. Improving communication with patients of all backgrounds can lead to improved health outcomes, better patient satisfaction, and better patient engagement.
Click here to see how Arine can help your organization address language barriers by delivering personalized care to your patients.
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