To improve communication between health care providers and their patients with limited English proficiency.
Develop affordable models that will help doctors, hospitals and their staff care for a changing patient population by funding ten demonstration sites in regions with established or emerging fast-growing Latino populations.
A growing body of research on health disparities between ethnic groups is making increasingly clear 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 Limited-English-Proficient (LEP) populations.
Language barriers create problems for both patients and providers. For patients, language and communication influence how and if LEP patients access and experience health care. Because of language barriers, 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 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:
- LEP patients receive less detailed information about rehabilitation therapy, 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
Language barriers often cause health care providers challenges in the following tasks:
- 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.
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 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 such as payments from Medicaid and Medicare.
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, some 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. State and Federal laws require healthcare providers and managed care organizations to have medical interpreters for LEP patients but typically do not define what constitutes adequate training or proficiency for interpreters.
The OCR guidelines are distilled into four key mandates:
Assessment. The organizations serving beneficiaries of federal programs must develop and implement a comprehensive written policy that will ensure meaningful communication.
Development of Comprehensive Written Policy on Language Access. The organizations serving beneficiaries of federal programs must develop and implement a comprehensive written policy that will ensure meaningful communication.
Training of Staff. The organizations serving beneficiaries of federal programs must take steps to ensure that staff understands the policy and is capable of carrying it out.
Vigilant Monitoring. The organizations serving beneficiaries of federal programs conducts regular oversight of the language assistance program to ensure that LEP persons meaningfully access the program. 8
The central issue of the debate following the OCR guidance has been that, despite a fairly broad sense in the health care community that 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 specifically addressed by federal funding.
Furthermore, there is little consensus around what constitutes adequate training for a medical interpreter, what constitutes quality translation of materials and not much is known empirically about the effectiveness of interpreter services.
Health care providers currently face the overwhelming challenge of meeting the cultural and language needs of wide array of subpopulations. This project chose to concentrate research on Latinos because of their growing numerical significance in the United States. Over the last ten years, the Latino population in the United States has grown to reach over 37 million, with Latinos representing 13% of all Americans. 9 The potential language barriers faced by Latino populations are also significant. The Census 2000 Supplementary Survey estimates that over 44 million Americans over the age of 5 speak a language other than English at home, and that for 62% of those 44 million, that language spoken in the home is Spanish.
In addition to their high growth and relative need of language services, working with Latinos-because of the wide variety of their countries of origin-offers a unique opportunity for insights into the interplay of culture and language in the health care setting. By specifically addressing language, we hope to learn more about what is needed for providers to effectively ensure equal access to health services for NEP and LEP populations.
According to the 2000 Census, the Hispanic population in the United States is 37 million. This number can be broken down into subgroups as follows:
Mexican: 20.6 million
Puerto Rican (living in the domestic U.S.): 3.4 million
Puerto Rican (living in Puerto Rico): 3.8 million
Cuban: 1.2 million
Other: 10 million
Central American: 1.7 million
Nicaraguan: 178, 000
Panamanian: 92, 000
Costa Rican: 69,000
South American: 1.4 million
Though the Latino population resides throughout the United States, knowing where its largest concentrations and most significant areas of growth are can help us understand where the language barriers issue may be most pressing. Some statistics:
- 43.5% of Hispanics live in the West
- 32.8% of Hispanics live in the South
- 14.9% of Hispanics live in the Northeast
- 8.9% of Hispanics live in the Midwest
- 4.2 million Hispanics live in Los Angeles County
- 42.1% of the total state population of New Mexico is Hispanic (the highest proportion for any state). 10
The health status of Latinos in the United States is complex, comprised by a population that experiences a variety of both health risks and unique protective factors.
According to a report published by the President's Initiative on Race in 1998 11, the following are some facts about Latino health status:
- Health status of younger groups of Hispanics may be declining.
- Hispanics (along with American Indians) face higher than average homicide rates.
- HIV kills black and Hispanic young adults at significantly higher rates than non-Hispanic whites, Asians or American Indians.
- Blacks and Hispanics are more likely to have disabilities and chronic disease than white elderly persons, but to some extent these differences are explained by differences in socioeconomic status.
- Hispanics are less likely to have health insurance than non-Hispanic whites.
- Hispanic infant mortality rates are equivalent to those of non-Hispanic whites, despite lower socioeconomic status of Hispanics.
- Hispanics have lower death rates than non-Hispanic whites for cancer and heart disease.
Given the demographic complexity of the Latino population in the United States, data has also been collected about the health status of Hispanic origin subgroups. According to a report published by the National Center for Health Statistics in February of 2000: 12
- Cubans report better health than other Hispanic origin subgroups (which included Puerto Rican, Mexican, and Other Hispanic).
- A larger percent of Puerto Ricans as compared with other Hispanic subgroups reported seeing a physician within the past year.
- Cuban individuals reported fewer days lost from school and/or work than the other three Hispanic origin subgroups.
- A higher percentage of Puerto Ricans had one or more hospital stay in the past year than other Hispanic origin subgroups.
- A greater percentage of Puerto Rican women considered themselves "current smokers" at the time of the study, than did members of other Hispanic origin subgroups.
- Cuban individuals reported having a higher level of knowledge about AIDS than members of other subgroups.
1-Shapiro J and Saltzer E (1981). Cross-cultural aspects of physician-patient communication patterns. Urban Health. Vol 10, 10-15.
2-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.
3-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.
4-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.
6-Section 601 of Title VI of the Civil Rights Act of 1964, 42 U.S.C. Section 2000d et. seq.
7-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.
9-LA Times, 1/21/03, Latinos Now Largest Minority.
10-The Hispanic Population. Census 2000 Brief.
11-Council of Economic Advisors for the President's Initiative on Race. "Changing America: Indicators of Social and Economic Well-Being by Race and Hispanic Origin." 1998 http://w3.access.gpo.gov/eop/ca
12-Hajat A, Luca JB, Kington R. Health outcomes among Hispanic subgroups: United States, 1992-95. Advance data from vital and health statistics; no. 310. Hyattsville, Maryland: National Center for Health Statistics, 2000.