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Language Alone Is Not Enough

Language Alone Is Not Enough 

Communication is much more than simply speaking the same language. To facilitate understanding with the person to whom you are speaking, there must also be an awareness and appreciation of where that person is coming from, literally. An awareness of that person’s culture, which extends to traditions, language, and beliefs, is vitally important when attempting to engage with and understand individualized reactions and assumptions. 

Addressing Disparities in Healthcare

Such cultural awareness is especially important when faced with key issues and concerns. Indeed, a lack of such awareness has been reported at the United States border with Mexico, where US officers have experienced difficulties communicating with indigenous people from Central America who speak no Spanish and come from locally specific indigenous cultures, speaking rare indigenous languages. See: “Child’s death highlights communication barriers on border,” Politico, 12/16/18,

According to the Commonwealth Fund’s December 27, 2018 issue of Transforming Care, cultural knowledge and appreciation of patient populations is essential to providing effective care while also addressing disparities in healthcare. 

Additionally, the article states: 

“…[f]ocusing on national data can mask important differences linked to whether Hispanics have health insurance, speak primarily Spanish or English, or grew up in the U.S. or another country. The very heterogeneity of the Hispanic population — they come from more than 20 countries, with widely differing experiences and social circumstances, including immigration status — makes it hard to pinpoint problems, including high rates of diabetes, liver disease, and certain cancers and poor birth outcomes among some Hispanic groups… 

Due to the fact that nearly a third of Hispanics in the U.S. are not fluent in English, many efforts to engage them begin with translation. But focusing on language alone can fall short, especially if the translation doesn’t take into account cultural differences. 

Transforming Care provides examples of how culturally appropriate care and attention can address cultural considerations while also reducing disparities in healthcare based on national origin, language, customs and beliefs. 

CalViva Health, a health plan serving Medicaid beneficiaries in California’s Fresno, Kings, and Madera counties, with support from  Health Net, a larger Medicaid plan, uses quality and claims data to identify disparities in healthcare among its members and then conducts interviews with patients and clinicians to uncover what may be fueling them.  

This approach revealed that in one rural clinic serving mostly Hispanic patients, many from El Salvador, only half of women attended postpartum visits between 21 and 56 days after delivery (as tracked by the  HEDIS performance measure). By comparison, in a nearby urban clinic also serving predominantly Hispanic patients,  though fewer Salvadorians, 73 percent of women had timely postpartum visits. 

The interviews revealed that many Salvadorian women follow the traditional practice of quarantining themselves after delivery: remaining in their homes for 40 days and covering their ears, nose, and other body parts to prevent evil spirits from entering the body. “Providers didn’t understand why they were coming in very heavily dressed, with ear plugs and long pants or sweats and socks in the summer and the members told us they felt their cultural practices weren’t being acknowledged,” said Eulalia Witrago, M.P.H, a senior cultural and linguistic specialist at Health Net. 

To encourage more Salvadorian women to attend postpartum visits, staff worked with clinics to educate clinicians about the quarantine practice and included a question (created in conjunction with Salvadorian women) to the obstetric history form about women’s cultural beliefs. CalViva staff have also helped clinics set up electronic reminders to schedule postpartum visits during women’s 35th week of pregnancy.”  

Harborview Medical Center in Seattle has a long-standing cultural mediators program, where the mediators help bridge the cultural gap with many patients. 

According to the Commonwealth Fund: 

For 24 years, cultural mediators have offered interpretation, health education, case management, and advocacy to patients with African, Asian, and other backgrounds; about 40 percent are Spanish speakers, and many are undocumented and/or uninsured. “It’s a really unique program,” says Lea Ann Miyagawa, M.N., R.N., assistant nurse manager of  Community House Calls. “There’s nothing else in the state like it and very few like it in the country.” 

… [Cultural mediator] José Mayorga also encourages clinicians to carefully consider their words, particularly related to end-of-life decision making.  Hispanics are less likely than white patients to have documented their end-of-life wishes, and in some cases their religious beliefs and distrust about physicians’ motives may complicate conversations about palliative care and end of life. “If a doctor is not careful and says, ‘There is nothing else I can do,’ patients may think the doctor’s knowledge is at its limits and say, “Let’s find a second opinion,’” he says. “But if a doctor explains that all efforts to save the patient were done, it will ease the process.” 

Mayorga has also helped honor Hispanic families’ traditions, once arranging for a priest to serve first communion to a child suffering from severe burns who was not expected to recover, and another time holding a quinceañera, or girl’s 15th birthday party, in the hospital so a sick grandfather could attend. “No mariachis,” he said, “but we had a party.” 

Effects of Cultural Appropriate Care

The comprehensive, culturally integrated approaches taken by numerous providers as highlighted by the Commonwealth Fund are making a difference – connecting clinics and hospitals with historically underserved populations through culturally and linguistically aware staff and care.  

The solutions discussed by the Commonwealth Fund represent lessons learned that are broadly applicable to all organizations. Bottom line – culturally and linguistically cognizant approaches are good business and good for the communities served. 

As the Commonwealth Fund notes: 

“The experiences of health plans and clinicians working to identify and reduce disparities in healthcare among different groups of Hispanics offer lessons for others. Some may be applicable to other low-income groups who face obstacles to accessing care because of their work hours, lack of transportation, or lack of income to devote to health. 

… “Where you were born shouldn’t matter,” says Michelle Doty, M.P.H., Ph.D., vice president of Survey Research and Evaluation for the Commonwealth Fund, who has studied Hispanic disparities in healthcare. “Ensuring people can get help to prevent or treat problems is a public health concern. There are no boundaries where there is illness in community, and so it behooves us to take care of everyone.” 


 **Read some of Bruce Adelson’s other blog posts to learn about more developments in language access law, and be sure to contact us if you’re interested in a consultation about your own organization’s compliance with federal language access law. Also, check out the blog “Communication Equals Understanding: The Effects of Increased Language Access for Patients” for more information about this subject.


© Bruce L. Adelson 2019, special for Bromberg, All Rights Reserved The material herein is educational and informational only.  No legal advice is intended or conveyed. 

Bruce L. Adelson, Esq, CEO of Federal Compliance Consulting LLC is nationally recognized for his compliance expertise concerning many federal laws.  Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney.   

Mr. Adelson is an Instructor of Family Medicine, Department of Family Medicine, at Georgetown University School of Medicine in Washington, D.C. 

He has also taught at Cornell University, Auburn University, Harvard University, and the University of Baltimore School of Law. 

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