Limited English proficient (LEP) people interact with health care providers, government agencies, and other organizations just as anyone else does – seeking health care at doctor’s offices, clinics, and hospitals; hotline, 911, or information line calls; emergency services such as police, fire, and urgent health care; outreach programs; public meetings and hearings; public access to agency websites; written materials or complaints sent to an agency; agency brochures intended for public distribution; and much more.
Yet, if LEP individuals are not afforded language assistance in their preferred spoken languages, their access to services is inequitable, or worse, unavailable. Such disparate access can have life threatening and other dangerous consequences, especially if people who cannot communicate in English have no meaningful access to health care.
According to a 2023 study by The Hastings Center (The Hastings Center addresses social and ethical issues in health care, science, and technology (https://www.thehastingscenter.org/who-we-are/our-mission/), “Health care systems’ medical interpreter services are inadequate and inefficient.”
“Over the past few decades, many major cities in the United States have become more diverse and gained more residents with limited English proficiency. Health care systems have attempted to accommodate these residents, but their medical interpreter services are inadequate and inefficient. The results can be delayed emergency care for children, an increase in medical errors and health care costs, and a decrease in care quality and patient satisfaction…
Patients without accurate translation services can’t describe their symptoms effectively. And, when they are discharged from the hospital, LEP patients are more likely than English-speaking patients to be readmitted. The reason for their readmission is not illness, but rather poor communication.
A lack of cultural sensitivity can cause a further disconnect in patient-provider communication and trust. For example, a 2022 study suggests that Hmong patients with LEP prefer having family members, instead of a professional interpreter, translate for them, which would be important to consider in hospitals with high Hmong populations, such as those in the Minneapolis-St. Paul metro area. However, ad-hoc interpreters, such as family and friends, cannot always accurately translate medical terminology. By contrast, Spanish-speaking Latinx patients report a preference for professional interpreters since they sometimes note feeling uncomfortable sharing confidential information in the presence of family and friends.”
Community health assessments {CHAs]assess the social determinants of health and partner with community organizations and residents to combat health inequity…
[T]he improvements to interpreter services outlined in each hospital’s [CHA] are vague and lack structure. Merely suggesting ‘increased access to interpreter services’ is a common but insufficient solution. Studies show that even when interpreter services are made accessible, clinicians still underuse them. One barrier cited is technical difficulty with interpretation technology…
[E]ven if a hospital employs a large team of professional interpreters, its interpreter services may not meet patients’ needs…
Hospitals should promote cultural competence by investing in diversity training. Diversity training in hospitals tends to be too general; the solutions suggested for addressing inequality are ambiguous and nonspecific. Including focus group responses from residents would provide more concrete recommendations to improve cultural competence. CH[A] data should also be incorporated into new employee orientations, which are mandatory and already include diversity training components. Furthermore, these orientations offer an opportunity to train staff on how to best utilize available interpreter services.”
A CHA refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis. Community health assessments must include the following:
- Multisector collaborations that support shared ownership of all phases of community health improvement, including assessment, planning, investment, implementation, and evaluation
- Proactive, broad, and diverse community engagement to improve results
- A definition of community that encompasses both a significant enough area to allow for population-wide interventions and measurable results, and includes a targeted focus to address disparities among subpopulations
- Maximum transparency to improve community engagement and accountability
- Use of evidence-based interventions and encouragement of innovative practices with thorough evaluation
- Evaluation to inform a continuous improvement process
- Use of the highest quality data pooled from, and shared among, diverse public and private sources.
Although the requirements are clear, CHAs often are less than accurate assessments of community health issues, especially the need for robust language assistance services, both interpretation and translation. Indeed, the salience of meaningful, accessible communication in health care is long standing and well-documented. For example, in 1994, the federal government developed and released The 10 Essential Public Health Services (EPHS), which describe the public health activities that all communities should undertake.
As described by the Centers for Disease Control, EPHS provide a framework for public health to protect and promote the health of all people in all communities. The Services were updated and revised in 2020.
“To achieve equity, the Essential Public Health Services actively promote policies, systems, and overall community conditions that enable optimal health for all and seek to remove systemic and structural barriers that have resulted in health inequities. Such barriers include poverty, racism, gender discrimination, ableism, and other forms of oppression. Everyone should have a fair and just opportunity to achieve optimal health and well-being.”
One of the 10 essential services is to “Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.” Without such effective communication, health care is simply neither equitable nor meaningful for the people who cannot understand what their doctors are advising them for their well-being.
To be complete, accurate, and to achieve the goals of the Affordable Care Act and EPHS, CHAs must describe and implement thorough, effective, and funded language services.
With complete CHAs, fully operational and effective language services, and effective training of staff, health care systems would be much better equipped than they are today to care for LEP populations fully and adequately in the United States. Such care must also include mandatory cultural awareness education for medical staff to remind them that cultural and linguistic differences are encountered daily in this country and are part of the lives of millions of Americans. Learning how best to reach and communicate with everyone is a necessary, non-negotiable part of health care.
As The Hastings Center reminds:
“Expecting patients to adhere to Western constructs of health communication is unfair and unjust. We must consider how linguistic differences and cultural values impact patients’ expectations and decision-making. By tailoring translation services to their LEP populations, health care systems can improve the quality of care for each of their unique and diverse patients.”
© Bruce L. Adelson 2023. All Rights Reserved The material herein is educational and informational only. No legal advice is intended or conveyed.
Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise. Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney. Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.
Mr. Adelson’s blogs are a Bromberg exclusive.