need for alternative solutions when caring for patients with language barriers

Barriers to quality communication increase the risk for misunderstanding, negatively impact the thoroughness of health investigations, and can lead to delayed diagnoses and increased readmissions. In addition, language barriers disproportionately affect the most vulnerable populations; thus, a lack of appropriate interpretation services promotes health disparities and increases the vulnerability of the underserved minority populations. According to the Act Respecting Health Services and Social Services of Quebec, health organizations need to take into account the distinctive linguistic and sociocultural characteristics of each region and, “foster […] access to health services and social services through adapted means of communication for persons with functional limitations”. A language barrier is a form of functional limitation that patients face when accessing healthcare services. Despite a clear policy, the current use of professional interpretation services is limited in our healthcare facilities, thus increasing obstacles in accessing healthcare services for patients with language barriers. It is thought that by identifying how language barriers present in our healthcare system and by highlighting the tools available to mitigate their consequences, healthcare workers, including medical students, may be better placed to serve the non-French and non-English speaking community. A group of medical students from the Universities of Montreal and McGill who are part of MedComm researched the problematic, most specifically in Montreal, in the hopes of emphasizing the need for alternative solutions to the current state of affairs in regard to offering optimal care to patients with language barriers.

Families of Deaf Children With Co-Occurring Disabilities

The authors of this chapter focus on immigrant families who have deaf children with co-occurring disabilities. The journey is filled with understanding deafness, co-occurring disabilities, resources, cultural impact, communication and amplification options, and navigating the American education system. The chapter covers a range of information for professionals and families to understand what families with deaf children with co-occurring disabilities face and the continuous decisions that must be made and implemented while having limited access to support due mainly to language barriers and cultural understand. The chapter covers from the time the deaf child with co-occurring disabilities is identified and the multiple layers to understanding the path the family takes, knowing each one is as unique as the child.

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

Perceptions and Experiences of Latinx Parents with Language Barriers in a Pediatric Emergency Department: A Qualitative Study

Background: Prior research has shown disparities exist among Latinx children who present to the pediatric emergency department (PED) for respiratory illnesses. Limited data exist regarding Latinx families’ perspectives on healthcare for their children in PEDs within non-traditional destination areas. Their perspective can identify areas of improvement for reducing healthcare disparities among pediatric patients within this population. The purpose of this qualitative study was to explore the perceptions and experiences of Latinx families with language barriers in the PED. Methods: Study staff screened the electronic health records of a purposive sample of patients. Families were considered eligible for the study if they: 1) presented to the PED with their 0-2 year-old child for a respiratory illness, 2) affirmed that their preferred language was Spanish at triage, and 3) requested a Spanish interpreter during registration. Semi-structured, one-on-one qualitative interviews were conducted via telephone, audiotaped, translated, and transcribed. All transcripts were reviewed using a thematic analysis. Results: Interviews were conducted with 16 Latinx parents. Thematic analysis revealed four major themes: (1) Uncertainty - Families expressed uncertainty regarding how to care for a child with distressing symptoms, (2) Communication – Families favored in-person interpreters which enhanced communication and allowed families to feel more informed, (3) Resources – Families reported that the unfamiliarity with the US health system and lack of resources are additional burdens, and (4) Closure – The emergency department visits garnered confidence and reassurance for families. Conclusions: The PED can be a key area of the health system that can help reduce disparities among the Latinx population. Further areas of intervention should focus on support beyond providing access to an interpreter, including identifying potential provider bias, improving information delivery, and enhancing education on community resources for families who face language barriers in the PED.

Disparities in Care and Outcome of Stroke Patients from Culturally and Linguistically Diverse Communities in Metropolitan Australia

Background: Acute stroke is a time-critical emergency where diagnosis and acute management are highly dependent upon the accuracy of the patient’s history. We hypothesised that the language barrier is associated with delayed onset time to thrombolysis and poor clinical outcomes. This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Baseline characteristics, thrombolysis time intervals, length of stay, discharge destination, and in-hospital mortality were compared among patients with and without a language barrier using multivariate analysis after adjustment for age, sex, stroke severity, premorbid modified Rankin Scale (mRS), and Charlson Comorbidity Index (CCI). Language barriers were defined as a primary language other than English. A total of 374 patients were included. Our findings show that 76 patients (20.3%) had a language barrier. Mean age was five years older for patients with language barriers (76.7 vs. 71.8 years, p = 0.004). Less non-English speaking patients had premorbid mRS score of zero (p = 0.002), and more had premorbid mRS score of one or two (p = 0.04). There was no statistically significant difference between the two groups in terms of stroke severity on presentation (p = 0.06). The onset to needle time was significantly longer in patients with a language barrier (188 min vs. 173 min, p = 0.04). Onset to arrival and door to imaging times were reassuringly similar between the two groups. However, imaging to needle time was 9 min delayed in non-English speaking patients with a marginal p value (65 vs. 56 min, p = 0.06). Patients with language barriers stayed longer in the stroke unit (six vs. four days, p = 0.02) and had higher discharge rates than residential aged care facilities in those admitted from home (9.2% vs. 2.3%, p = 0.02). In-hospital mortality was not different between the two groups (p = 0.8). In conclusion, language barriers were associated with almost 14 min delay in thrombolysis. The delay was primarily attributable to imaging to needle time. Language barriers were also associated with poorer clinical outcomes.

Cataract Surgery Outcomes and Postoperative Patient Compliance in Limited English Proficiency Patients at a County Hospital

Background/Aims: Investigate the role of language barriers in cataract surgery outcomes at a county hospital. Methods: Retrospective chart review of patients who underwent cataract surgery March 2018-February 2019 at Lyndon B. Johnson Hospital. Patients who underwent cataract surgery combined with another procedure or had severe glaucoma or proliferative diabetic retinopathy were excluded. Patients were classified into limited English proficient (LEP) or English proficient (non-LEP) groups based on language preferences. Demographics, baseline ocular characteristics, intraoperative complications, postoperative BCVA (best-corrected visual acuity), complications, and compliance were recorded. The primary outcome was incidence of poor visual outcomes (BCVA<20/40) at the postoperative 1-month visit. Results: 354 patients (199 [56%] LEP and 155 [44%] non-LEP) with 125 (35%) males and a mean age 66.1 (+/- 10.9) years were included. LEP patients were about 5 years older than non-LEP patients (P<0.001) and were mostly Hispanic (172 [86%] LEP vs. 36 [26%] non-LEP, P<0.001). The baseline ocular characteristics were similar (P >0.05), except severity of cataract (125 [63%] NSC grade >2+ for LEP vs 70 [51%] for non-LEP, P =0.03). No significant differences in intraoperative complications (P =0.18), incidence of poor vision (P =0.59), postoperative cystoid macular edema (P =0.32), and compliance with the postoperative drop regimen (P =0.11) were noted. Conclusion: There were no statistically significant differences in incidence of poor vision, complications, or compliance. However, there was a trend toward significance, showing that language barriers may lead to more advanced disease and compliance issues with postoperative medications.

Evaluation of a Language Translation App in an Undergraduate Medical Communication Course: Proof-of-Concept and Usability Study

Background Language barriers in medical encounters pose risks for interactions with patients, their care, and their outcomes. Because human translators, the gold standard for mitigating language barriers, can be cost- and time-intensive, mechanical alternatives such as language translation apps (LTA) have gained in popularity. However, adequate training for physicians in using LTAs remains elusive. Objective A proof-of-concept pilot study was designed to evaluate the use of a speech-to-speech LTA in a specific simulated physician-patient situation, particularly its perceived usability, helpfulness, and meaningfulness, and to assess the teaching unit overall. Methods Students engaged in a 90-min simulation with a standardized patient (SP) and the LTA iTranslate Converse. Thereafter, they rated the LTA with six items—helpful, intuitive, informative, accurate, recommendable, and applicable—on a 7-point Likert scale ranging from 1 (don’t agree at all) to 7 (completely agree) and could provide free-text responses for four items: general impression of the LTA, the LTA’s benefits, the LTA’s risks, and suggestions for improvement. Students also assessed the teaching unit on a 6-point scale from 1 (excellent) to 6 (insufficient). Data were evaluated quantitatively with mean (SD) values and qualitatively in thematic content analysis. Results Of 111 students in the course, 76 (68.5%) participated (59.2% women, age 20.7 years, SD 3.3 years). Values for the LTA’s being helpful (mean 3.45, SD 1.79), recommendable (mean 3.33, SD 1.65) and applicable (mean 3.57, SD 1.85) were centered around the average of 3.5. The items intuitive (mean 4.57, SD 1.74) and informative (mean 4.53, SD 1.95) were above average. The only below-average item concerned its accuracy (mean 2.38, SD 1.36). Students rated the teaching unit as being excellent (mean 1.2, SD 0.54) but wanted practical training with an SP plus a simulated human translator first. Free-text responses revealed several concerns about translation errors that could jeopardize diagnostic decisions. Students feared that patient-physician communication mediated by the LTA could decrease empathy and raised concerns regarding data protection and technical reliability. Nevertheless, they appreciated the LTA’s cost-effectiveness and usefulness as the best option when the gold standard is unavailable. They also reported wanting more medical-specific vocabulary and images to convey all information necessary for medical communication. Conclusions This study revealed the feasibility of using a speech-to-speech LTA in an undergraduate medical course. Although human translators remain the gold standard, LTAs could be valuable alternatives. Students appreciated the simulated teaching and recognized the LTA’s potential benefits and risks for use in real-world clinical settings. To optimize patients’ and health care professionals’ experiences with LTAs, future investigations should examine specific design options for training interventions and consider the legal aspects of human-machine interaction in health care settings.