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Language Barriers in American Healthcare: Addressing Disparities for Patients with Limited English Proficiency
“Me siento intoxicado,” gasped the 18 year old William Ramirez, seconds before collapsing at a school event and being rushed to a South Florida hospital. In the ambulance, his girlfriend repeatedly said “intoxicado”, which was misinterpreted by the paramedics as “intoxicated” (Sulaiman). When Ramirez woke up from a 48 hour coma, he was paralyzed because clinicians did not know that “intoxicado” can also mean “sick to the stomach” and treated him for a drug overdose; in reality, his upset stomach was a symptom of a brain aneurysm. This simple miscommunication caused by a language barrier resulted in an 18 year old young man being left a quadriplegic for life and a $71 million dollar malpractice lawsuit (Sulaiman). The case of William Rameriz exemplifies the unacceptable treatment of many patients with Limited English Proficiency (LEP) in America.
Even in far less extreme examples, the inability to communicate effectively and directly with healthcare providers causes LEP patients to experience worse health outcomes, and it is essential that we consider the ethics of the issue to further develop solutions for treating patients when a language barrier is present. William Ramirez is one of many victims of a healthcare system that is not suited to address the needs of its population. A large body of evidence from peer reviewed research shows that patients with limited English proficiency in America suffer worse health outcomes because of their experiences in healthcare, as well as larger sociocultural factors. Unfortunately, the most common solution for addressing the language barrier in healthcare, the use of medical interpreters, holds many limitations, which complicates the existing ethical dilemmas of relational and distributive injustice. I argue that language concordance, when a clinician and patient are able to communicate directly through the same language, is the optimal solution because it minimizes communication errors, allows LEP patients to explain themselves directly, helps to build rapport and relationships between patients and providers, and it gives these patients more satisfactory healthcare experiences.
According to the 2019 U.S. Census Bureau report, the population of those who speak another language other than English at home makes up 67.8 million Americans, which is almost 1 in 5 people (Dietrich and Herdandez). Furthermore, around 39% of this group reported speaking English “less than well” (Healthy People 2030: Language and Literacy). Not only is the inability to proficiently speak English a dire challenge for navigating the American healthcare system, but the language barrier often correlates to having lower health literacy. The U.S. Department of Health and Human Services defines health literacy as the “degree to which individuals and organizations find, understand, and use health-related information or services”. With an understanding of how many Americans are being affected by limited English proficiency and even low health literacy, it is crucial that we examine how these circumstances manifest into disparities and the solutions at hand. The disparities of the language barrier are manifested before, during, and after receiving healthcare.
LEP patients experience challenges before they have even entered a provider’s office. Access to healthcare is a broad term that refers to finding proper health insurance, finding providers, scheduling appointments, and so on. Finding appropriate care poses a challenge to LEP Americans because these systems are not always offered in a variety of languages, which adds to the stress of accessing healthcare. In the article “Barriers in Healthcare for Latinx Patients with Limited English Proficiency—a Narrative Review,” a study of 1344 patients surveyed by a health department found that “25% of patients with LEP reported difficulty scheduling appointments, and 29% of Spanish-speaking patients, compared to 10% of English-speaking patients, did not report resolution of medical conditions after a doctor’s appointment” (qtd. in Escobedo 1265). Additionally, the review discusses another study that interviewed 20 Latinx patients, concluding that inferior care led to issues such as misidentification in records, lack of Spanish-language services, and perceived discrimination (Escobedo et al. 1265).
Ultimately, these studies exemplify that Spanish-speaking Americans faced with a language barrier are having more troubles accessing care and that something as seemingly simple as scheduling an appointment can be a stressor for LEP patients because of misinterpretations and perceived discrimination. If a patient cannot properly access the care they need and advocate for themselves, they experience worse outcomes and insufficient treatment.
LEP patients with chronic diseases particularly experience significant barriers and disparities in treatment. In a study published in the Journal of Racial and Ethnic Health Disparities, authors Chen and others interviewed and quantitatively surveyed 69 Asian Americans living with HIV. From the four main themes revealed from their qualitative data analysis, the study found that a common issue for the participating Asian Americans was “impeded access to HIV health services” (Chen at el.). Most of the participants were immigrants, and because of their unfamiliarity with the local healthcare systems, there was often delayed HIV testing. One of the study participants, a 69 year old male, stated, “I couldn’t speak English… I had no idea I could get those services here. I could have come to check [my] HIV status two years earlier” (Chen at el.). The inability to understand a diagnosis or advocate for the resolution of your symptoms is a challenge faced by LEP Americans that directly causes worse health outcomes, such as the progression of an untreated chronic disease. Furthermore, seeking healthcare becomes more complicated with a disease as heavily stigmatized as HIV and with the perceived discrimination of low English proficiency. In sum, nearly all the participants in this study faced barriers in finding appropriate HIV services, which resulted in delayed treatment, and therefore, more suffering and dissatisfaction for these LEP patients. The sociocultural factor of being a non English speaking immigrant, with the inherent stigma of an HIV diagnosis, also contributes to the barrier of finding and receiving necessary care.
Once patients access necessary healthcare services, there comes a plethora of implications in the practice and delivery of care. A study published in the Journal of General Internal Medicine aimed to measure the differences between language concordant and discordant care among older Asian American immigrants. The authors, Ngo-Metzger et al., found that “language discordant patients had 61% greater odds of rating their providers as fair or poor compared to language concordant patients” (327). Even when these patients were provided with a clinical interpreter, they were still significantly more likely to be unsatisfied with their providers (Ngo-Metzger et al. 327).
This finding aligns with other studies that have examined various language populations and their levels of satisfaction with language discordant care. Furthermore, in Escobedo et al.’s narrative review on barriers in healthcare for LEP Latinx patients, the authors note that “dissatisfaction with healthcare increases risk of hospitalization, limits access to care, and may also drive mistrust in the healthcare system among patients with LEP” (1264).
The language barrier in clinical settings creates significant disparities for LEP patients because it makes them less comfortable seeking care. This dissatisfaction fosters historical mistrust in healthcare, reduces the likelihood of patients continuing their care, leaves their needs unmet, and ultimately causes unnecessary stress.
It is not simply that LEP patients are less satisfied with their care; the language barrier has been shown to cause negative health consequences. Espinoza and Derrington state that poor communication affects “the clinician’s understanding of the patient’s symptoms, which complicates diagnoses and interventions, prompts inadequate or excess testing,” and it results in differences in hospital stays and increased morbidity and mortality when compared to English proficient patients (110). The inability to speak the same language as your provider causes poorer health outcomes and a complicated, often misinterpreted treatment process, which prompts these patient’s dissatisfaction. Once again, there is evidence that dissatisfaction with healthcare providers deters LEP patients from continuing to seek care, furthers cultural distrust in authority, and leads to misdiagnosis, unmet needs, and untreated symptoms.
Several institutional problems exacerbate language barriers that contribute to the unmet needs, unsatisfactory experiences, and poor health outcomes experienced by LEP patients. In Healthy People 2030, the United States Department of Health and Human Services explains that a “lack of well-trained interpreters and culturally competent health care providers adversely affects the health of LEP patients.” For instance, LEP patients often receive lower quality mental healthcare because of poorly trained interpreters who may “normalize” or “omit pathological symptoms” due to their inherent biases and stigmas (Healthy People 2030: Language and Literacy). The poor health outcomes seen in LEP patients is not only attributable to a language barrier, but rather, inherent stigmas, bias, and discrimination associated with limited English proficiency play a heavy role in the delivery of healthcare. The delivery of care across a language barrier is further complicated by lacking cultural competence. In sum, healthcare delivery across a language barrier is causing worse health outcomes, and in turn lower, patient satisfaction.
Finally, on the tail end of healthcare, after LEP patients have accessed and received care, the language barrier causes disparities in post-discharge settings. Authors Espinoza and Derrington in their article “How Should Clinicians Respond to Language Barriers That Exacerbate Health Inequity?” state that patients with LEP faced with a language barrier not only have poor clinical encounters, but they also experience “decreased comprehension of medical instructions” and are “less comfortable with post-discharge care regimens” (110). In Escobedo’s et al. narrative review, the authors cite a study looking at the pharmacy records of 3205 Latinx LEP patients, 5755 English speaking Latinx patients, and 21,878 English speaking White patients with diabetes (1266). The study found that LEP correlates to lower oral diabetes medication and insulin adherence (Escobedo et al. 1266). The narrative review also looked at another study about postpartum women who had used interpreters, and it found that these women had better pain control, more timely pain treatment, and better clinical satisfaction (Escobedo et al. 1266). When a language barrier is present, patients may not fully comprehend discharge instructions like pharmacological instructions, and therefore, they are less successful in the treatment of their disease. Poor medication adherence and unfulfilled post discharge plans exacerbate and progress symptoms, which complicates the treatment process. Once again, the inability to understand and process health information due to language discordant care drives disparities in this population.
In Chen’s et al. “Lost in Translation” article about Asian Americans with HIV, one of the qualitative themes found was “decreased antiretroviral adherence.” The article found from completing in-depth interviews that the majority of these LEP Asian American patients had trouble understanding their HIV diagnosis, talking about their diagnosis with their provider, and understanding prescription instructions. The inability to comprehend your diagnosis and follow discharge instructions directly leads to negative health outcomes because it causes delayed onset of treatment or poor medication adherence. A 49 year old female participant in the study said, “because I didn’t understand English and didn’t know what HIV was, I did not take my medication”, and on top of this, she did not even fully understand her diagnosis until she was later rehospitalized as her symptoms worsened (Chen et al.). The language barrier poses a significant risk for delayed treatment and poor treatment adherence in LEP patients, which obviously results in poorer health for LEP patients because they are uninformed on how to properly tend to their ailments and diseases. With diseases such as HIV that can progress into more complicated diagnoses or cause secondary infections, the lack of urgency and efficiency in care regimes is particularly harmful to these patients.
It is clear that the language barrier causes negative health outcomes and poor experiences when trying to access care, in clinical interactions, and in post discharge regimens. There are many more barriers faced by LEP patients that were not covered, such as lesser access to preventive screenings, time constraints, immigration status, financial barriers, and lack of formal education. Regardless of these other challenges, the consequences and disparities caused by language barriers in healthcare are also transgenerational. In Espinoza and Derrington’s article, they note that children of parents with LEP are “more likely to be uninsured, lack a medical home and specialty referrals, and experience serious errors” compared to children with English proficient parents (110). It is clear that limited English proficiency and language barriers in healthcare are causing tangible disparities, in the form of poorer health outcomes and dissatisfaction, for these patients and their families. The most prominent solution for treating non English patients is by attempting to provide language concordance via medical interpreters, but it is important that the limitations of interpreters are addressed because their use does not always improve outcomes.
I argue that medical interpreters are not a sufficient solution for the disparities seen in low English proficiency patients because they are insufficiently trained, underutilized, and unsuccessful. In an article posted on HealthAffairs.org, the text discusses the research on some of the benefits of using medical interpreters, such as “decreased readmission rates, increased health care use, and improved patient outcomes” (Ortega and Shin). Even though medical interpreters have been argued to have some mitigating effects on the language barrier’s ability to cause disparities, they are not always available and still have pitfalls. For instance, the Ngo-Metzer et al. study found that the use of interpreters actually exacerbated the disparities of poor clinical interaction ratings, and those with an interpreter were more likely to rate their provider as poor or fair (327). It is burdensome to have to relay information about private health matters through a third party, and there are social discrepancies and a lack of patient-clinician rapport when direct communication is not possible. In another study discussed in Ortega and Shin’s article, it was found that “encounters with interpreters had an average of 31 communication errors.” It appears that there is just as much evidence of interpreters’ harm as there is for their benefit.
Lastly, medical interpreters are not sufficient to bridge the gap for LEP populations because there is a lack of standardization in their use. The Culturally and Linguistically Appropriate Services (CLAS) guidelines recommend using qualified bilingual providers and language assistive services (medical interpreters), but research shows that only 13% of hospitals are compliant with their standards (Derrington and Espinoza). Furthermore, the training and recruitment of medical interpreters varies from one institution to the next, not all clinicians choose to use them, and only “23% of training clinicians received instruction on working with interpreters” (Derrington and Espinoza). LEP patients may have a variety of language concordant services at one providers’ office and none at the next, which in itself, is a disparity. The inconsistency of medical interpreters makes healthcare access and delivery unpredictable for LEP patients.
Given the significant limitations of medical interpreters, it is clear that language concordance is the optimal solution for the issue at hand, but I attest that training programs and incentives for culturally competent, bilingual clinicians would have the greatest mitigating effects on these disparities. Taking one final look at the Ngo-Metzer et al. study on this topic, the study concluded that language concordance is the best solution for addressing the language barrier because it results in higher satisfaction rates with their clinicians and interpersonal care and more patient health education (327). LEP patients should have satisfactory experiences uncomplicated by miscommunications with timely resolution of their symptoms, just as English proficient Americans do. The problem must be addressed because it an issue of distributive and relational injustice.
As a healthcare provider, there are legal and ethical obligations to treat all patients equally and as competently as possible. Furthermore, having limited English proficiency and the language barrier is out of these patient’s control, and we cannot expect all Americans to speak English or have the time and resources to learn it. However, that does not excuse the inequities dealt to this population, as America’s history is coined as a melting pot of culture and ethnicities. First, the disparities attributed to language barriers are examples of “distributive injustice”, which are “poor health outcomes as a result of decreased access” (Derrington and Espinoza 111). As previously discussed, LEP causes restricted healthcare access due to difficulties scheduling appointments, identifying patient records, and accessing practices that offer assistive linguistic services, which exemplifies distributive injustice. Furthermore, in a study assessing malpractice claims in four states, a portion of these claims were related to “failure to provide competent language interpretation”, which was supported by evidence of “patient harm, inappropriate language use in medical care, and high financial costs” (Ortega and Shin). These malpractices exemplify implications of distributive justice, as they are related to a lack of interpreters. LEP patient’s pursuit for optimal health and a disease free life is hindered by institutional factors and poorly distributed resources that are out of their control and prevent them from receiving equitable care.
LEP patients experiencing language barriers in healthcare are also victims of “relational injustice”, which involves the “devaluation of identities” via societal and institutional normalities (Derrington and Espinoza 111). Relational injustice is a product of biases, stigma, discrimination, stereotypes, and acculturation, which are institutionally unaccounted for. For instance, the Escobedo et al. narrative review cites a study that identified an association between “machismo values, perceived discrimination, and medical mistrust” in 499 Latinx patients interviewed in rural Oregon (1267). With the cultural context of strong, traditional masculine roles in the Latinx community, on top of perceived discrimination, there is mistrust in the medicine in this population because being treated as less than, or less intelligent, in clinical settings challenges these machismo values. Lack of cultural competence is an example of relational injustice because a patient’s values and identity should not be degraded or lost in the processes of healthcare. Furthermore, another study cited in the review interviewed racial and ethnic minorities with lung cancer and found that this population is more likely to agree with “fatalistic statements”, such as “my ethnic group cannot trust doctors” ( Escobedo et al. 1267). When providers are unaware of the cultural context of their LEP patients and communities’ historic values, this lack of awareness can further medical mistrust and deter LEP patients from the healthcare system. This is relational injustice because LEP patients’ experience a loss of cultural identity when they enter a healthcare system that does not understand their background, their cultural context, and does not meet their unique needs.
In another instance of relational injustice, the Chen’s and others’ study claims that discrimination, HIV disclosure, and issues accessing healthcare causes stress during the acculturation process. Furthermore, this study found that language barriers “increased Asian Americans’ [living with HIV] perceived stigma and are associated with level of acculturation” (Chen et al.). Language barriers complicate the acculturation process, and those who are not well adjusted to American culture have a harder time navigating the healthcare system. Trying to assimilate to a new environment that predominantly speaks another language, let alone the American healthcare system, is even more difficult and stressful when dealing with chronic disease. Alongside the lack of cultural competency in the treatment of LEP patients, the experience of discrimination and feeling stigmatized adds to the issue of relational injustice because the institutions that are supposed to be providing care are actually creating unpleasant experiences of perceived oppression. Equal access and equitable experiences in healthcare should be a right, not a privilege.
All in all, 1 in 5 Americans do not speak English at home and are faced with a language barrier in the American healthcare system (Dietrich and Hernandez). Research shows that it is more difficult for these patients to access care, such as having difficulty making appointments and lack of available language services, which manifests into delayed disease treatment. In practice, LEP patient’s needs and symptoms are often left unaddressed, they are left unhappy with their experience, and they experience much worse health outcomes. After leaving clinical experience, LEP patients struggle to understand their diagnosis, adhere to post-discharge and pharmaceutical instructions, and their children are more likely to suffer similar disparities. Furthermore, medical interpreters are insufficient because they do not mitigate poor interpersonal experiences, are unstandardized, and are readily unavailable. Increasing the number of culturally competent, bilingual providers would mitigate both relational and distributive injustice while lessening the disparities because patients would be able to directly and clearly communicate with a provider who understands the cultural context in which they reside. In sum, there are countless disparities in the form of worse health outcomes experienced by LEP Americans due to the language barrier in healthcare. Healthcare should be a right, as opposed to a privilege, regardless of the language one speaks. Moving forward, solutions must be implemented to eliminate disparities and promote ethical and equitable healthcare delivery in America.
Author: Claire Reader, Class of 2025
In my English 110 section, we read the book Language vs Reality by N.J. Enfield and were asked to take inspiration for our research topics. After briefly exploring language prompting in health-related media and behavioral therapy, I decided to investigate language in a more literal sense. With some Spanish courses under my belt, I considered my own difficulties in attempting to learn another language. In conjunction with an understanding of health disparities and systemic barriers from my public health coursework, I began researching the experiences of those navigating the American healthcare system with low-English proficiency. Even as a native English speaker, finding appropriate care is not always easy. From this perspective, I decided to focus on how navigating the system across a language barrier contributes to health disparities in LEP patients, the current solutions and practices in use, and the ethical dilemmas in the healthcare system’s shortcomings for LEP patients.
Throughout and during the research process it was clear that language barriers are contributing to worse health outcomes and unsatisfactory experiences in Americans with LEP and that the current solutions in use are inconsistent, widely unstandardized, and not always effective. Although it is a difficult problem to tackle, addressing the social determinants of health, eliminating access barriers, and fostering cultural competency is still needed to meet the needs of all Americans. In sum, exploring language barriers in healthcare gave me an opportunity to learn about how disparities are manifested in language discordance and the pitfalls of medical interpreters. The writing process allowed me to further explore public health, the career field I am pursuing, while gaining an understanding of some of the work that is needed moving forward to promote health equity.
Instructor: Mike Haen
The unofficial title of this E110 section was “Language: The Good, The Bad, and The Ugly.” In the first five weeks, we read chapters from the book Language vs. Reality (2022) and considered these big questions about language: What is language good for? What does it do for us? And, what does it do to us? By reading about and discussing various themes such as (1) framing in media and political discourse and (2) the role of language in social coordination and the formation of social relationships, students start to develop their research interests. They then wrote a research proposal that included their guiding question and four relevant sources. Claire was interested in how language barriers affected healthcare delivery and health outcomes for patients with Limited English Proficiency. After her strong proposal, Claire compiled an outstanding annotated bibliography that addressed the effects of language barriers on a range of groups, including Asian American and Latinx patients. She carefully selected different kinds of scholarly sources including peer-reviewed studies and narrative/literature reviews of language barriers and their effects on patients. Her final essay is an outstanding exploration of how language can exclude vulnerable people and how healthcare providers can mitigate that problem.
Works Cited
Chen, Wei-Ti, et al. “Lost in Translation: Impact of Language Barriers and Facilitators on the Health Care of Asian Americans Living with HIV.” Journal of Racial and Ethnic Health Disparities, 2023, https://doi.org/10.1007/s40615-023-01674-7.
Dietrich, Sandy, and Erik Hernandez. “Nearly 68 Million People Spoke a Language Other Than English at Home in 2019.” Census.Gov, 6 Dec. 2022, www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html.
Escobedo, Luis E., et al. “Barriers in Healthcare for Latinx Patients with Limited English Proficiency—A Narrative Review.” Journal of General Internal Medicine, vol. 38, 31 Jan. 2023, pp. 1264–1271, https://doi.org/10.1007/s11606-022-07995-3.
Espinoza, Jason, and Sabrina Derrington. “How Should Clinicians Respond to Language Barriers That Exacerbate Health Inequity?” American Medical Association Journal of Ethics, vol. 23, no. 2, Feb. 2021, pp. 109–116, https://doi.org/https://journalofethics.ama-assn.org/sites/default/files/2021-02/cscm3-2102.pdf.
“Healthy People 2030: Language and Literacy.” Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/language-and-literacy.
Ngo-Metzger, Quyen, et al. “Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use.” Journal of General Internal Medicine, vol. 22, no. S2, 24 Oct. 2007, pp. 324–330, https://doi.org/10.1007/s11606-007-0340-z.
Ortega, Pilar, and Tiffany M Shin. “Language Is Not A Barrier—It Is An Opportunity To Improve Health Equity Through Education.” Health Affairs, 30 July 2021, www.healthaffairs.org/content/forefront/language-not-barrier-opportunity-improve-health-equity-through-education.
Sulaiman, Anita. “The Impact of Language & Cultural Barriers on Patient Safety & Health Equity.” Foundation For Health Care Quality, WA Patient Safety, 13 Oct. 2017, www.qualityhealth.org/wpsc/2017/10/13/impact-of-language-cultural-barriers-on-patient-safety-health-equity/.
Tsoh, Janice Y., et al. “Healthcare Communication Barriers and Self-Rated Health in Older Chinese American Immigrants.” Journal of Community Health, vol. 41, no. 4, 8 Jan. 2016, pp. 741–752, https://doi.org/10.1007/s10900-015-0148-4.