Immigration and Health Disparities

Migration continues to be an important component of globalization. With global movement comes migrants’ vulnerability, and the consequent intersection with health and health disparities. The immigrant population in the United States is expected to increase to about eighty-one million by 2050. This ongoing demographic transformation suggests that the health status, health risk behaviors, and health disparities of immigrants and their offspring may play a significant role in shaping the health outcomes of the American population. Immigrants are particularly considered a vulnerable population because of insufficient access to and utilization of health care, limited English proficiency, low socioeconomic status, immigrant status, stigmatization, marginalization, and increased risk for poor physical, psychological, and social health outcomes, especially among the working poor. These factors undoubtedly have detrimental effects on the health and health disparities of immigrants and their children. These social, environmental, and behavioral occurrences or life experiences accumulate over time to improve or jeopardize an individual’s health. Similarly, immigration policies have a tremendous impact on immigrant health disparities, especially during periods of strict and intense enforcement in the United States. Nativity has become a prominent domain in health disparities research. Given that nativity, racial, and ethnic health disparities continue to be a major public health concern, social work scholars and practitioners continue to work toward eliminating health disparities among population subgroups, including immigrants. Included in these discussions are immigrant health service use, immigrant health effects, salmon bias, and determinants of immigrant health. Also important in working with immigrants are problems with accessibility to health services.

Understanding Medication Adherence in Patients with Limited English Proficiency

Introduction. Approximately 41.6% of the US population who speak a language other than English (20% over all) and have limited English proficiency (LEP) status.1 Health outcomes for patients with LEP status or who are language discordant (speak a different language than their clinicians) have been studied in several settings, including the hospital and outpatient, with results widely demonstrating that these patients have worse outcomes when a professional interpreter is not used consistently. 2,3 The aim of this study was to investigate the impact of preferred language and language discordance on medication adherence. Methods. Data were collected via review of pharmacy-acquired medication profiles for three primary language cohorts: Nepali, Spanish, and English. Total Days of Adherence, Adherence Ratio, and Maximum Days Non-adherent were calculated and compared between language groups. We examined these statistics for regular and long-acting insulin, metformin and ACE inhibitors, testing for differences between language groups and those who experienced greater vs less than the median value for language concordant clinical encounters. Results. The most adherent group over all (highest adherence-ratio) were the Nepali-speaking, but the results showed high variability across outcomes and medications. Conclusions. After adjustment and stratification for greater vs lesser language concordant patient visit experience, we found that language-spoken plays an important role in the clinical encounter, and that LEP patients could have improved outcomes in their adherence to medications by having providers who speak their language or use an interpreter.

Overcoming the language barrier: a novel curriculum for training medical students as volunteer medical interpreters

Background Over 41 million people in the United States speak Spanish as their primary language, of which 16 million have limited English proficiency (LEP). It is well-established that language barriers contribute to health disparities and that the use of ad-hoc interpretation by untrained family members results in substandard care. We developed a novel interpreter training program for medical students to serve as in-person interpreters at a charitable, resident continuity clinic so as to overcome the language barrier in the delivery of healthcare to LEP patients. Methods The Medical Student Interpreter Training Program (MSITP) consists of three steps. First, fluent Spanish-speaking students shadowed a licensed interpreter. Second, students took a standardized phone exam to demonstrate language proficiency. Finally, students completed a three-hour training on the methodology and ethics of interpreting conducted by the Department of Interpreter Services. Results Pre- and post-tests were administered to assess students’ familiarity with the Interpreter Code of Ethics and interpreter skills. Familiarity with the Interpreter Code of Ethics increased significantly with all students reporting feeling comfortable (47%) or very comfortable (53%) after training. The pre- and post-tests included free response questions, which were administered to assess competence in the methodology and ethics of interpreting. The cohort’s aggregate score increased by 35% after the training (Wilcoxon signed rank z-score = 2.53; p = .01). Conclusions Implementing the MSITP resulted in an increased number of trained, Spanish-speaking interpreters available to provide their services to LEP patients at an affiliated charitable clinic and throughout the university hospital. Unlike other program models which are time and resource-intensive, this program is replicable and easily managed by volunteers. The MSITP is an effective model for training students as medical interpreters to ensure the delivery of quality healthcare for LEP patients.

Crowdsourcing Translation for Community-Based Tourism Empowerment in Thailand

English has not only become a lingua franca for global communication, but it also carries a symbolic power that influences local people and stakeholders in community-based tourism (CBT) in Thailand. Thai villagers encounter communicative challenges due to their limited English proficiency. Thai-English speaking tour guides are valued, as they provide translation services on behalf of CBT members whose interactions with foreign tourists are minimal and marginalized. Losses in translation regarding local wisdom and heritage are inevitably unavoidable. This chapter addresses a conceptual model of crowdsourcing translation for CBT. The study hopes that the sociolinguistic and cultural gaps can be bridged for the enhancement of other CBT communities. Crowdsourcing in the form of collaborative translation and volunteering translators' efforts can potentially provide an alternative lens for possible translation scenarios. Tourism operators and stakeholders can apply these practices to assist the local people to promote lesser-known tourist attractions in remote areas in Thailand.

Fostering Successful Communities of Collaboration Through Educational Partnerships

There is an undisputable need to form collaborative partnerships between schools, families, homes, and communities across the nation. Collaborative educational partnerships are the cornerstone for student success. With increasingly diverse student populations, schools must communicate and collaborate with families and communities to bridge the wide gap that exists between home and school. With a dominant Spanish-speaking population of Mexican descent, as that of children living in the Southern tip of the Texas-Mexican border, known as The Rio Grande Valley, barriers such as low social economic status and limited English proficiency may impede much-needed communication between schools, homes, and communities. These barriers that negatively impede student success must be replaced with strong bridges that support student achievement. Recommendations are anchored in opportunities to increase academic and social partnerships among schools, families, homes, and communities. The premise for establishing educational partnerships is ultimately student achievement and success.

Assessing Medical Student Readiness to Navigate Language Barriers in Telehealth: A Cross-Sectional Survey Study (Preprint)

BACKGROUND The COVID-19 pandemic has massively increased telehealth usage in the U.S. Patients with limited English proficiency (LEP) face barriers to healthcare, which may be mitigated when providers work with professional interpreters. However, telemedicine may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers. OBJECTIVE To investigate advanced medical students’ confidence in caring for patients with LEP during telehealth encounters. METHODS We administered a written survey to medical students on clinical clerkships in one U.S.-based institution between August to September 2020. We assessed students’ overall confidence in working with interpreters; confidence in performing eight clinical tasks in in-person versus telehealth encounters; and frequency of performing five different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed rank tests and chi-squared tests were used to compare confidence and task performance frequency respectively for patients with LEP vs. English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free response was qualitatively analyzed using open coding to categorize barriers (key themes). RESULTS Of 300 medical students surveyed, 121 responded. 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (p<0.001), developing trust (p<0.001), identifying agenda (p=0.005), eliciting preferences for diabetes management (p=0.012), and empowering patient in lifestyle modifications (p=0.044) during telehealth encounters. During both in-person and telehealth encounters, nearly half of students (40-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building. CONCLUSIONS Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the U.S. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure in order to ensure high quality care for linguistically diverse patients. CLINICALTRIAL N/A

Discordance Between Satisfaction and Health Literacy Among Spanish-Speaking Patients with Limited English-Proficiency Seeking Emergency Department Care

Introduction: The emergency department (ED) is one clinical setting where issues pertaining to health communication uniquely manifest themselves on a daily basis. This pilot study sought to understand satisfaction with care, perceptions of medical staff concern, awareness, and comprehension of medical care among Spanish-speaking patients with limited English-language proficiency (LEP). Methods: A two-phase, mixed-methods approach was employed among Spanish-speaking patients with LEP that presented to an ED in West Central Florida. The prospective phase consisted of semistructured interviews ( n = 25). The retrospective phase analyzed existing patient satisfaction data collected at the study site ( n = 4,940). Results: Content analysis revealed several linguistic barriers among this patient population including limited individual autonomy, self-blame for being unable to effectively articulate concerns, and lack of clarity in understanding follow-up care plans. Retrospective analysis suggested differences between responses from Spanish-speaking patients when compared with their English-speaking counterparts. Conclusions: Our findings suggest discordance between satisfaction and health literacy in this unique patient population. Although high satisfaction was reported, this appeared to be secondary to comprehension of follow-up care instructions.