Exploring the 'Patient Experience' of Individuals with Limited English Proficiency: A Scoping Review

Language of Caregiver and Pediatric Day-of-Surgery Cancellations

OBJECTIVE

To examine the relationship between language used by a caregiver and day-of-surgery cancellations, and to distinguish whether neighborhood opportunity influences this relationship.

STUDY DESIGN

We performed a retrospective study of 173 533 children <18 years of age at a single institution who were scheduled for ambulatory surgery from 2017 through 2022. We estimated the odds of day-of-surgery cancellation by caregiver language, stratifying by neighborhood opportunity. We then determined the relative excess risk due to interaction of language other than English (LOE) with neighborhood opportunity.

RESULTS

Day-of-surgery cancellation occurred in 3.7% and 5.2% of children with caregivers using English and LOE, respectively (P < .001). Children from disadvantaged neighborhoods with caregivers using English had 23% lower odds of cancellation than those using LOE for care (OR 0.77, 95%CI 0.71-0.85; P < .001). Children from advantaged neighborhoods with caregivers using English had 38% lower odds of cancellation than those using LOE for care (OR 0.62, 95%CI 0.52-0.72; P < .001). The interaction between language and neighborhood advantage was not significant, indicating that neighborhood advantage does not appear to buffer those using LOE from cancellations (relative excess risk due to interaction: -0.06, 95%CI -0.21 to 0.08; P = .40).

CONCLUSIONS

Children with caregivers using LOE for care experience higher odds of day-of-surgery cancellation than children with caregivers using English, regardless of neighborhood opportunity. Decreasing language barriers is key to equitable surgery access.

The impact of language discordance on genetic counselors' ability to establish a working alliance with patients

We explored the impact of language discordance (LD) on quality of care by asking genetic counselors (GCs) about their perception of how their lack of proficiency in a patient's language affects their sessions. We hypothesized that contracting, which relies on ongoing, bidirectional communication between GC and patient, is particularly vulnerable to LD. Specifically, we evaluated the impact of dialogue engagement (whether GCs ranked dialogue as more one-sided/rigid or more interactive/conversational), time sufficiency (how adequate the GCs ranked the time allotted for the session), and interpreter-related factors (experience and relationship with interpreters; perceived ability and knowledge of how to work with interpreters) on GCs' perceived ability to contract in LD sessions. Forty-five GCs recruited from the NSGC listserv completed a 42-item survey exploring these topics through reflection on their most recent LD and language concordant (LC) sessions. The outcome measure of "perceived contracting success" was defined based on five practice-based competencies. Results were analyzed using Wilcoxon signed ranks tests and linear regressions and found that GCs' perceived (1) contracting success, (2) dialogue engagement, and (3) time sufficiency were significantly lower in LD sessions (p < 0.001 for all 3). Perceived contracting success in LD sessions had a positive relationship with both perceived dialogue engagement and perceived time sufficiency (r2 = 0.312, 0.103). Also, perceived dialogue engagement increased with higher perceived time sufficiency and trust in the interpreter (r2 = 0.235, 0.27). Our study is the first to quantitatively explore factors impacting perceived contracting success in LD GC sessions and suggests that LD may hinder communication and session tailoring. This highlights the importance of GCs being more intentional about having interactive dialogue with patients in LD sessions, considering allotting more time for LD sessions, and meeting with the interpreter prior to LD sessions to establish a trusting relationship.

Applying dynamic dyadic systems to explore features of relationship-centered care among Spanish and non-Spanish speaking patients

OBJECTIVE

Relationship-centered care (RCC) positions the exchange between patient and provider as central to patient care. Due to limitations in analytical approach, how the relational exchange develops throughout the clinical visit remains unclear. Dynamic dyadic systems (DDS) perspectives overcome these limitations to reveal interdependencies and evolving patterns in turn-taking sequences within dyads. We applied DDS analyses to examine how features of RCC manifest during clinical visits with Spanish-speaking Latinx and English-speaking non-Latinx patients.

METHODS

We analyzed transcripts from 13 primary care visits (5 with Latinx patients, 8 with non-Latinx patients). Interaction turns totaled N = 2394 units of analysis. Dyadic time series plots examined the trajectory of clinical encounters and contributions made by patients and providers. Sequence analysis identified distinct turn patterns-or conversational motifs among dyads.

RESULTS

Conversational motifs reflected four patterns. In our example, motif distribution differed such that with Latinx Spanish-speaking patients, the provider largely engaged in patient-focused probing dialogue, while relational features of communication were underrepresented. In contrast, with non-Latinx English-speaking patients, providers engaged in more instructive exchange.

CONCLUSION

Results support DDS to analyze patient-provider communication by illustrating interdependencies in reciprocal exchange and inequities in RCC delivery.

PRACTICE IMPLICATIONS

Findings demonstrate opportunities for behavioral change to enhance cultural sensitivity in the delivery of care.

Communication After Emergent Surgery by English Proficiency: An Exploratory Qualitative Study

INTRODUCTION

Older adults with Limited English Proficiency (LEP) comprise a disproportionate number of trauma and emergency general surgery (EGS) patients. In other settings, this group experiences barriers to communication that are likely exacerbated by acute surgical admission. Despite their likely vulnerability, this topic remains understudied. We conducted an exploratory qualitative study to understand communication of older adults with English Proficiency (EP) and LEP hospitalized for trauma or EGS.

MATERIALS AND METHODS

Trauma/EGS service inpatients aged ≥65 with mild or no cognitive impairment were purposively sampled at a safety-net, level one trauma center. Semi-structured interviews were held with patients and family when present, using interpreters for LEP. Interviews transcripts were 20% triple-coded and thematically analyzed using modified grounded theory within an interpretivist paradigm. LEP transcripts were also examined for interpretation errors.

RESULTS

Twenty-three patients enrolled, 8 with LEP (Spanish, Cantonese, Russian). Three themes emerged: 1. Lack of Information - both groups expressed limited knowledge of their care 2. Loss of Autonomy - both groups endorsed reliance on providers. 3. Feedback and Advocacy - Participants with EP and family members of LEP critiqued care and endorsed the importance of self-advocacy; participants with LEP were reluctant to offer critical feedback. All interviews with professional interpreters contained errors.

CONCLUSIONS

Differences in EP and LEP participants' self-advocacy and critiques suggest that language proficiency and communication style contribute to communication barriers after trauma and EGS. Difficulties are likely compounded by professional interpreter errors. Our study generates foundational evidence for further exploration of these factors and their effects on patient outcomes.

Appraisal of Spanish-language online patient education resources for kidney stones

INTRODUCTION

The internet is a primary source of health information, our study addresses the need to assess the credibility, readability, and reliability of Spanish-language medical websites concerning nephrolithiasis. With the Spanish-speaking population in the United States rapidly approaching 20% and growing, our research endeavors to fill a critical gap by evaluating the quality of online resources in Spanish for this common medical condition.

METHODS

In our study, we evaluated the quality of Spanish-language online resources on nephrolithiasis for the growing Spanish-speaking population in the United States. Using Google searches with terms like "cálculos renales" and "nefrolitiasis," we analyzed 80 unique websites using Fernandez-Huerta readability software, HON-code certification, JAMA benchmark criteria, source classification, and brief DISCERN. The evaluation was performed by an expert urologist and a medical student, with discrepancies resolved by a third experienced reviewer.

RESULTS

Interrater reliability was strong for JAMA (ICC: 0.98) and DISCERN (ICC: 0.85). Websites mainly originated from Physician/Community Hospitals (43.75%) and University/Academic institutions (23.75%). Only 32.5% had HON-code certification, and 17.5% met all JAMA criteria. Readability typically matched an 8th to 9th grade level, but 58.75% scored below the good quality threshold on DISCERN, with University/Academic sources performing significantly better than Physician/Community sources (p = 0.0078). No significant differences were noted in credibility or readability between these groups.

CONCLUSIONS

Our findings indicate that Spanish-language resources on nephrolithiasis often lack in quality, readability, and credibility, highlighting the need for enhanced online materials to support patient and provider management of kidney stones. University sources provide notably higher-quality information than other resource types.

New Index Demonstrates Association between Social Vulnerability, Environmental Burden, and Kidney Failure Risk among Individuals with Glomerular Disease

Key Points

More tools are needed to explore upstream drivers of racial and ethnic disparities in kidney disease outcomes. The Centers for Disease Control and Prevention Environmental Justice Index is a new tool which characterizes cumulative social and environmental burden at the census tract level. This study is the first application of the Environmental Justice Index to understanding glomerular disease outcomes.

Background

The Centers for Disease Control and Prevention Environmental Justice Index Social-Environmental Ranking (EJI-SER) combines a Social Vulnerability Module with an Environmental Burden Module to characterize cumulative environmental and social burden at the census tract level. This analysis evaluates the association between EJI-SER and kidney outcomes in patients with glomerular disease (GD).

Methods

Cure Glomerulopathy is an observational cohort study of adults and children with biopsy-proven GD. EJI-SER is a percentile ranking by census tract, with a higher score indicating a more severe burden. Associations between EJI-SER and its components with kidney failure (initiation of KRT, transplant, or two eGFRs <15 ml/min per 1.73 m2) and longitudinal eGFR were tested using multivariable Cox regression and linear mixed models, respectively, adjusted for demographics, histologic diagnosis, eGFR and urine protein to creatinine ratio at enrollment, and time from biopsy to enrollment.

Results

Among 1149 participants with census tract data, the median (interquartile range [IQR]) follow-up was 5.4 (3.0–7.0) years, the median (IQR) age at biopsy was 24 (10–48), and self-identified racial distribution was 5% Asian, 18% Black, and 70% White. Median (IQR) EJI-SER was 0.49 (0.26–0.75). EJI-SER scores in the lowest two quartiles were associated with a lower hazard of kidney failure compared with the highest quartile (adjusted hazard ratio [95% confidence interval], 0.62 [0.36 to 1.08] and 0.43 [0.25 to 0.76] for EJI-SER 0%–25% and >25%–50% versus >75%, respectively) and higher eGFR at enrolllment (adjusted mean 90.1 versus 87.1 ml/min per 1.73 m2 for 0%–25% versus >75%, P = 0.08).

Conclusions

As captured by EJI-SER, higher environmental and social burdens are associated with lower eGFR and a higher risk of kidney failure in the Cure Glomerulopathy cohort. This first use of the EJI-SER in GD demonstrates the need for additional investigation into social drivers of disparities in GD and policies and resources that address these structural inequities.

What services are available for culturally and linguistically diverse (CALD) patients in the cancer survivorship setting? An Australian study

PURPOSE

People of Culturally and Linguistically Diverse (CALD) backgrounds face disparities in cancer care. This study aimed to explore CALD-specific Cancer Survivorship (CS) resources and supports in Australian oncology centres.

METHODS

This was an interview-based, qualitative study. Oncology professionals were interviewed using a questionnaire exploring demographics, available resources and referral patterns, and factors influencing CALD CS care. Purposive sampling was used to ensure representation across states and remoteness areas. Contextual survey data were analysed with descriptive statistics, and interviews were recorded and transcribed for thematic analysis.

RESULTS

Twenty-two interviews from 15 institutions across 6 Australian states were conducted from May to August 2023. Six (40%) centres reported seeing > 25% CALD patients. Six (40%) centres reported having dedicated CS services dichotomised into clinic-based or needs-based services. Ten (67%) centres reported having CALD-specific resources/supports for oncology patients, and three (20%) had CS-specific services. Four themes were identified: patient-clinician interface; in-language resources with a focus on cultural relevance; structural and logistical considerations, particularly interpreter services, workflow management and models of care; and education and collaboration between healthcare professionals and survivors, carers and community leaders.

CONCLUSIONS

Cancer survivors from CALD backgrounds face unique challenges in receiving optimal care, with limited availability of CALD-specific resources in Australian cancer centres. Future work should utilise a tailored and collaborative approach to optimise cultural relevance and service engagement.

Reported severity of psychotic, depressive and anxiety symptoms in relation to bilingual language profile: An exploratory study and the validation of Basque versions of the PQ-B, DASS-42, PHQ-9 and GAD-7

BACKGROUND

Language plays a crucial role in health care and especially in mental health, since the use of the native language helps to make a good diagnosis as several studies have shown.

AIM

We studied the influence of language on the accurate detection of psychotic and affective symptoms, exploring differences in the severity of reported symptomatology in a bilingual Basque-Spanish population.

METHODS

The study uses the Prodromal Questionnaire-Brief for the detection of psychosis and the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7, and Depression, Anxiety and Stress Scale-42 for the assessment of stress, anxiety and depression. Basque versions of the scales were developed and their psychometric properties were evaluated in a sample of 623 individuals, including 521 from the general population and 102 psychiatric patients. Possible relations between questionnaire scores and four linguistic factors, namely first language (L1), proficiency, age of acquisition and language exposure, were examined.

RESULTS

The four translated questionnaires showed adequate sensitivity, goodness-of-fit, and reliability indices, thus validating their suitability for general and clinical settings. The results showed that reporting of depressive symptoms seemed to be modulated by linguistic variables, mainly L1, whereas the severity of psychotic symptoms was less reliably associated with the gathered linguistic factors.

CONCLUSIONS

Overall, our results suggest that language of assessment by means of written instruments may have a limited impact on healthcare outcomes in balanced bilingual populations. The study enriches the understanding by considering various linguistic factors beyond L1, and by exploring the effect of these factors on affective symptoms, apart from psychotic ones.

Traditional and Online Health Information Seeking Among Individuals With Limited English Proficiency in the United States: Cross-Sectional Study

PURPOSE

We investigate how individuals with Limited English Proficiency (LEP) seek, access, and evaluate traditional and online sources they rely on for health information.

DESIGN

Retrospective cross-sectional survey analysis from the United States.

SETTING

Pooled Health Information National Trends Survey surveys (2013-2019).

SUBJECTS

The sample was comprised 15,316 respondents; 236/15,316 (1.54%) completed the survey in Spanish and 1727/14,734 (11.72%) had LEP (did not speak English "very well"). The sample was nationally representative across demographic categories.

MEASURES

Independent and dependent variables were self-reported using validated measures.

ANALYSIS

Multivariable logistic regression models using jackknife replicate weights for population estimates.

RESULTS

Adults with LEP were less confident in their capacity to access health information (aOR = 0.59, CI: 0.47-0.75) and had less trust in health information from medical professionals (aOR = 0.57,CI: 0.46-0.72) than English proficient (EP) adults. Although LEP and EP adults were both most likely to use the internet as their first source of information, LEP adults were more likely than EP adults to consult health professionals, print sources like books, news or brochures, family and friends, television and radio. Spanish language survey respondents were more likely to trust health information from government agencies (aOR = 1.99, CI: 1.09-3.62) and watch health-related videos on the internet than respondents who took the survey in English (aOR = 2.51, CI: 1.23-5.12).

CONCLUSION

Our results show how language barriers may contribute to health disparities experienced by linguistic minorities. Government agencies and health care organizations need to promote health information dissemination in underserved communities and may need to embrace the use of alternative information sources such as television, radio, and the internet to reach LEP populations.

The Experiences of Families of Hospitalized Children Who Use Languages Other Than English

BACKGROUND/OBJECTIVES

Patients who use a language other than English (LOE) for health care communication are at increased risk of experiencing adverse events and worse outcomes. The objectives of this research are (1) to understand the lived experience of families who speak LOEs around the hospitalization of their child and (2) to understand the perspectives of patients and families who speak LOEs on opportunities to improve their experiences during hospitalization.

METHODS

This study is grounded in patient- and family-informed research. We designed a qualitative study involving children hospitalized in the general pediatric inpatient unit at a Canadian children's hospital. We conducted semistructured individual interviews with children and families with a medical interpreter. We used thematic analysis, and all interviews were coded by 2 reviewers.

RESULTS

A total 20 families of 16 different languages participated in the interviews. Themes important to understanding their lived experience were the following: (1) communication uncertainty-families experienced inconsistent interpreter use and availability, which affected in-the-moment communication and families' ability to understand the overall clinical context, leading to increased uncertainty; (2) lack of belonging-despite communicating that they had positive experiences in the hospital, families described a lack of belonging and felt that they were "other" during hospitalization; (3) altered trust-in addition to language, each patient/family's unique and complex social contexts contribute to developing an altered trust relationship with the health system that impacts their engagement in care processes. Families described opportunities for improvement such as supporting patient-initiated interpretation, increasing workforce diversity, and tailoring concepts such as shared decision making to their realities.

CONCLUSIONS

Patients and families also revealed that they experience communication uncertainty, altered trust, and a lack of belonging within the hospital setting. Our research builds on the current literature and serves to advance our efforts to address health inequities experienced by this population.

The Importance of Patient Experience in Obtaining Mental Health Care at HRSA-Funded Health Centers

Timely mental health care prevents more complex and costly psychological problems, particularly for underserved individuals utilizing HRSA-funded health centers. Patient experience with care services and provider interactions may facilitate timely mental health care access. This study explored which elements of patient experience at health centers minimize delayed access to necessary mental health care. We used cross-sectional data on adult patients who needed mental health services from the 2022 Health Center Patient Survey (N = 1039). Multi-variable logistic regression analyses examined the influence of patient experience using measures drawn from the Consumer Assessment of Healthcare Providers and Systems on delayed mental health care, accounting for predisposing, enabling, and need factors. 82% of patients did not cite delayed mental health care. 60% or more of patients reported always or usually receiving responsive and coordinated care, with over 80% reporting always or usually receiving positive provider interactions. Lower odds of delayed mental health care was associated with always getting timely callback during business hours (adjusted odds ratio [aOR]: 0.26; 95% confidence interval [CI]: 0.09, 0.76), and that the provider always listened carefully (aOR: 0.33; CI: 0.14, 0.78), provided easy to understand recommendations (aOR: 0.31, CI: 0.12, 0.79), knew the patient's medical history (aOR: 0.33, CI: 0.15, 0.73), was respectful to the patient (aOR: 0.49, CI: 0.27, 0.90), or was easy to understand (aOR: 0.51, CI: 0.29, 0.88). Care responsiveness and positive provider communication are integral to facilitating timely mental health care access for vulnerable populations with mental health needs.

Physicians' Perspectives on Using Direct Observation to Assess Non-English Language Proficiency for Clinical Practice: A Qualitative Study

BACKGROUND

Communication barriers are known to adversely affect patient safety. Yet few health systems assess and track physician non-English language proficiency for use in clinical settings. Barriers to current assessments (usually simulated clinician oral proficiency interviews) include time constraints and lack of interactivity. This study's objective was to investigate physician perspectives on using direct clinical observation as an alternative form of assessment of their non-English language skills.

METHODS

The authors conducted semistructured interviews with 11 fully and partially bilingual primary care physicians (general internists) from a large academic health system to understand physician perspectives on using direct observation as an alternative form of assessing non-English proficiency for use in clinical practice. Two researchers independently and iteratively coded transcripts using thematic analysis with constant comparison to identify themes.

RESULTS

Participants, mostly women (n = 9; 81.8%), reported varying levels of proficiency in Cantonese, Mandarin, Russian, or Spanish. Participants expressed three main themes: (1) benefits of direct observation, including familiar setting, relevant content, and convenience; (2) disadvantages, including discomfort, potential embarrassment, and limitations of observing a single encounter; and (3) suggestions to enhance use of direct observation tools, such as observing multiple encounters, and use of remote observation.

CONCLUSION

To ensure high-quality language-concordant care, health systems must assess physicians' non-English language proficiency. If validated tools can be developed and disseminated in clinical practice, direct observation may be an acceptable option.

Experiences of communication in the neonatal intensive care unit for mothers with a preferred language other than English

OBJECTIVE

To understand the experiences of mothers with a preferred language other than English (PLOE) in communicating with staff and engaging in the care of their hospitalized infant.

DESIGN

We qualitatively analyzed a previously collected and a prospective dataset comprised of transcripts of 36 interviews with Spanish-, Haitian Creole-, and Brazilian Portuguese-speaking mothers of preterm infants from 3 NICUs. We applied the constant comparative method to develop codes and themes, which were inductively structured using the socio-ecological framework.

RESULTS

We identified themes across socio-ecological levels: Individual (unaddressed language barriers, varied maternal empowerment, and justification of suboptimal interpreter use); Interpersonal (family-staff language concordance facilitating engagement, positive impact of non-interpreted informal interactions, and differential treatment based on maternal language status); Institutional (system-level interpretation barriers and varied interpreter service quality).

CONCLUSION

Mothers with PLOE face multilevel communication and engagement barriers in the NICU; we discuss potential interventions to improve equity in these areas.

Regional Distribution of Foreign-Born Medical Graduates in US Primary Care Specialty Residencies from 2010 to 2022

BACKGROUND

The United States has more foreign-born (FB) individuals than any other country and a large international medical graduate (IMG) workforce. Yet little is known about the trends of FB IMGs matching into primary care specialties residency programs or the alignment between FB individuals and FB IMGs.

OBJECTIVE

This study examined the recent trends in FB IMGs entry into primary care specialty residency programs and their distribution in relation to the US FB population.

DESIGN

In this retrospective study, we used archives of National Resident Matching Program (NRMP) data on the main residency match from 2010 to 2022.

MAIN MEASURES

We extracted match data and program directors' policies for internal medicine, pediatrics, family medicine, and internal medicine/pediatrics. We also extracted data on the total population and FB individuals from the US Census Bureau for each US state from 2010 to 2022.

KEY RESULTS

From 2010 to 2022, 17.2% of primary care specialty positions were filled by FB IMGs, with 22.1% for internal medicine, 11.3% for pediatrics, 10.7% for family medicine, and 3.2% for internal medicine/pediatrics. The percentage of primary care specialty positions filled by FB IMGs was significantly higher than the percentage of FB people in the US overall and 7 of 9 US regions (p < 0.001) (excepting Pacific and Mountain). The percentage of family medicine, pediatrics, and internal medicine/pediatrics positions filled by FB IMGs was significantly lower than the proportion of FB people (p < 0.001). Internal medicine had a higher proportion of positions filled by FB IMGs compared to the proportion of FB individuals in the general population (p < 0.001).

CONCLUSION

Distribution of FB IMGs varies in primary care specialties compared to FB people in the US. Given the importance of aligning medical education with patients' needs, programs could take into account population demographics while assessing and admitting the applicants.

Monitoring Use of Language Interpreting Services for Patients with Limited English Proficiency: Methods to Match Patient Medical Records with Interpreter Billing Logs

BACKGROUND

Over 60 million patients in the USA have limited English proficiency (LEP) and experience barriers in care. Still, there exists no standardized method of monitoring the utilization of language interpreting services (LIS).

OBJECTIVE

To introduce a methodological approach to systematically monitor utilization of LIS for LEP patients.

DESIGN

We utilized a One-To-Many Match algorithm to align inpatient visits of LEP patients from the electronic health record (EHR) with corresponding calls from LIS billing logs, using a unique patient identifier (MRN) and LIS call dates within patient's admit and discharge dates. Due to error when MRNs are recorded by LIS, the FuzzyWuzzy Probabilistic String-Matching technique was utilized to enhance match accuracy where exact matches were unattainable, addressing inherent complexities in language data matching.

PARTICIPANTS

The study involved 5823 inpatient encounters with a non-English preference in an urban hospital system in 2020, representing a linguistically diverse patient base, and attempted to match these against 183,655 LIS call logs.

MAIN MEASURES

Our approach successfully matched 83.1% (4389 out of 5823) of inpatient encounters to an LIS call.

KEY RESULTS

We observed significant language-specific disparities in LIS usage, with Spanish leading in call volume at 2737 calls (exact matches) and 845 (probabilistic matches). Concordance rates varied, exceeding 94% for all languages in exact matches and ranging from 53.9% for Arabic to 71.6% for Russian in probabilistic matches. The average frequency of LIS calls was about one call per day per language group in the inpatient setting.

CONCLUSIONS

The study provides vital insights into language service preferences, frequency, and duration. These findings emphasize the need for standard methods in monitoring LIS usage to enhance patient outcomes for LEP patients.

How Can Clinical Communication Alleviate the Negative Impacts of Social Determinants of Health?: A Secondary HINTS 6 Dataset Analysis

Structural disparities (eg, food insecurities, housing, and lack of transportation) at different social levels (eg, personal, family, and community) are strong determinants of health, influencing individuals' and population well-being worldwide. Research is scarce examining how clinical communication can mitigate the negative impact of social disparities obstructing the reception of quality healthcare. In this study, we explore the mediation role of patient-centered communication (PCC) between social determinants of health (SDH) and quality of care. Using a sample of 5437 adult who visited a healthcare provider in the past 12 months from the sixth Health Information National Trends Survey (HINTS 6), our key points of findings included that the models showed PCC partially mediating the connections from (a) "skipped meals" (effect = -.08, 95%CI = [-.12, -.04]), (b) "unaffordable meals" (effect = -.08, 95%CI = [-.11, -.05]), (c) "fear of eviction" (effect = -.1, 95%CI = [-.14, -.06]), and (d) "lack of transportation" (effect = -.12, 95%CI = [-.16, -.08]) to quality of care (QoC). Specifically, better communication had a positive impact on mediating the disparities; poor communication did not. Demonstrating in a nationally representative sample, our findings indicate the key role of patient-centered clinical communication in effectively alleviating the inherent challenges faced by people with low health literacy and socioeconomic status. Theoretical and practical implications are discussed.

Identifying the Health Educational Needs of Refugees: Empirical Evidence from a Delphi Study

Refugees experience poorer health outcomes especially which can be exacerbated by or can be a result of low health literacy of refugee populations. To address poor health outcomes, health literacy, and health usage in refugee populations, it is essential to develop health educational interventions for refugees' healthcare integration. To do so, learning objectives must be identified based on refugees' health knowledge gaps. Therefore, the overall aim of this study is to identify these knowledge gaps. A modified Delphi method was employed for this study with three rounds of survey: the first to identify learning objectives, the second to prioritise learning objectives, and the third to categorise the learning objectives as not recommended, partially recommended, or highly recommended. An overarching theme of utilising the healthcare system and its various services effectively and efficiently was recognised to be an important learning objective for educational interventions to address refugees' health integration. Overall, learning objectives within the theme self-care and preventative health were ranked as most important.

It's More Complicated Than Interpreter Use: Improving Care for Non-English-Speaking Families

Mateo is a 2-week-old male who presented for evaluation of neonatal fever and whose parents speak Spanish. Workup revealed pyelonephritis, underlying renal anomalies, and vesicoureteral reflux. A complex interplay of individual and contextual factors contributed to Mateo not receiving prophylactic antibiotics, which ultimately led to a potentially preventable subsequent admission for sepsis secondary to Escherichia coli pyelonephritis with bacteremia. Further history revealed additional communication breakdown; despite multiple appointments between hospitalizations, systems issues led to Mateo's primary care provider being unaware of Mateo's admissions or urologic diagnoses. This case demonstrates challenges facing health care providers as we strive to provide equitable care to families speaking languages other than English (LOE). Although an in-person interpreter was used throughout Mateo's hospitalization, there were still key areas of communication breakdown and opportunities for improvement. First, we describe characteristics of the growing population speaking LOE in the United States and discuss qualitative and quantitative disparities in health care encounters for this population. Through Mateo's experience, we highlight the transition of care at discharge as being highly vulnerable to communication breakdown, particularly for patients speaking LOE, and emphasize the additional impact of low health literacy on these challenges. Finally, we outline potential strategies to reduce disparities and improve outcomes for pediatric patients and families speaking LOE, focusing on (1) consistent and evidence-based interpreter use, (2) incorporation of health literacy-informed communication strategies in the discharge process, (3) reducing barriers to follow-up appointments or diagnostic testing, and (4) closed-loop communication with the patient's primary care provider.

Association of non-English language preference with postoperative hospital visits among California Medicaid enrollees

BACKGROUND

Patients with non-English language preference encounter language barriers across phases of surgical care. Patients with a non-English language preference represent 35% of California households and are disproportionately insured by Medicaid. To determine whether language predicts surgical outcomes, we investigated the association of patient non-English language preference with postoperative emergency department visits and readmissions among California Medicaid enrollees.

METHODS

Our retrospective analysis of adult Medicaid enrollees undergoing 1 of 10 common inpatient operations using California hospital administrative data (2016-2019) modeled the association between non-English language preference and 30-day postoperative emergency department visits and readmissions using mixed effects logistic regression with hospital random intercept, adjusting for patient, operation, hospital, and community characteristics. Secondary analyses stratified by operation urgency and by insurance type in an all-payor cohort.

RESULTS

Of 115,527 Medicaid enrollees, 17.2% had non-English language preference (n = 19,881), 66% were female (n = 73,653), and 40% were Hispanic/Latino (n = 45,541). Patients with non-English language preference experienced fewer postoperative emergency department visits (non-English language preference: 13.5%, English preference: 17.9%, P < .001) and readmissions (non-English language preference: 7.5%, English preference: 8.5%, P < .001), which persisted in adjusted models (adjusted odds ratio emergency department, 0.80, 95% confidence interval, 0.77-0.85; readmissions: adjusted odds ratio, 0.86, 95% confidence interval, 0.80-0.92). Non-English language preference was associated with fewer emergency department visits after elective (adjusted odds ratio, 0.80; 95% confidence interval, 0.73-0.88) and urgent/emergent surgery (adjusted odds ratio, 0.80; 95% confidence interval, 0.75-0.85) but not readmissions after elective surgery (adjusted odds ratio, 0.89; 95% confidence interval, 0.78-1.01). This pattern was only observed for Medicaid and not other insurance types.

CONCLUSION

Patients with non-English language preference who receive Medicaid have fewer postoperative emergency department visits and readmissions, even after urgent surgery. Our findings suggest that patterns of health care seeking after surgery vary by patient language, and investigating explanatory mechanisms is needed.

Cancer survivorship programs for patients from culturally and linguistically diverse (CALD) backgrounds: a scoping review

PURPOSE

People of Culturally and Linguistically Diverse (CALD) backgrounds face disparities in cancer care. This scoping review aims to identify the breadth of international literature focused on cancer survivorship programs/interventions specific to CALD populations, and barriers and facilitators to program participation.

METHODS

Scoping review included studies focused on interventions for CALD cancer survivors after curative-intent treatment. Electronic databases: Medline, Embase, CINAHL, PsycInfo and Scopus were searched, for original research articles from database inception to April 2022.

RESULTS

710 references were screened with 26 included: 14 randomized (54%), 6 mixed-method (23%), 4 non-randomized experimental (15%), 2 qualitative studies (8%). Most were United States-based (85%), in breast cancer survivors (88%; Table 1), of Hispanic/Latinx (54%) and Chinese (27%) backgrounds. Patient-reported outcome measures were frequently incorporated as primary endpoints (65%), or secondary endpoints (15%). 81% used multi-modal interventions with most encompassing domains of managing psychosocial (85%) or physical (77%) effects from cancer, and most were developed through community-based participatory methods (46%) or informed by earlier work by the same research groups (35%). Interventions were usually delivered by bilingual staff (88%). 17 studies (77%) met their primary endpoints, such as meeting feasibility targets or improvements in quality of life or psychological outcomes. Barriers and facilitators included cultural sensitivity, health literacy, socioeconomic status, acculturation, and access.

CONCLUSIONS

Positive outcomes were associated with cancer survivorship programs/interventions for CALD populations. As we identified only 26 studies over the last 14 years in this field, gaps surrounding provision of cancer survivorship care in CALD populations remain.

IMPLICATIONS FOR CANCER SURVIVORS

Ensuring culturally sensitive and specific delivery of cancer survivorship programs and interventions is paramount in providing optimal care for survivors from CALD backgrounds.

Virtual discharge counseling: An assessment of scalability of a novel patient educational process across a multi-site urban emergency department

BACKGROUND

Inadequate counseling at patient discharge from the emergency department can lead to adverse patient outcomes. Virtual discharge counseling can address gaps in discharge counseling and improve patients' understanding of instructions.

METHODS

A previously established virtual discharge counseling program was scaled across three emergency departments and expanded to 13 diagnoses. Utilizing a standardized protocol and script, counselors performed virtual discharge counseling via a remote, secure teleconference platform in the patients' preferred language.

RESULTS

Virtual discharge counseling was performed with 166 patients. COVID-19, back pain, and headache were the most frequent diagnoses. The median counseling time was 14 min. Median counseling time for English was 11 min, versus 20 min for other languages (p < 0.001). Counseling times were the longest for COVID-19 and diabetes (18 min for each).

CONCLUSION

We demonstrate the scalability of a virtual discharge counseling program. Our findings can assist in targeting virtual discharge counseling resources for limited English-proficiency patients and specific diagnoses that require longer counseling times.

A Public Health Ethics Framework for Populations with Limited English Proficiency

25.6 Million people in the United States have Limited English Proficiency (LEP), defined as insufficient ability to read, write, or understand English. We will (1) Delineate the merits of approaching language as a social determinant of health, (2) highlight pertinent public health values and guidelines which are most relevant to the plight of populations with LEP and (3) Use the COVID-19 pandemic as an example of how a breakdown in public health ethics values created harm for populations and patients with LEP. We define a framework to tease out public health responsibilities given some populations' limited proficiency in a society's predominant language. The American Public Health Association (APHA) public health ethics core values serve as a framework to interrogate current practices. We use the COVID-19 case to illustrate gaps between health policy and healthcare disparities experienced by populations with LEP.

Examining the association between professional language interpreter services and intensive care unit utilization among patients with non-English language preference: Evidence from a large U.S. hospital

OBJECTIVE

To examine the healthcare utilization of patients with non-English language preference (NELP) who utilized a professional language interpreter (PLI) in the intensive care unit (ICU) compared to similar patients with NELP who did not utilize a PLI in the ICU.

METHODS

Single center cohort study of patients with NELP with at least one ICU admission a large academic medical center in the U.S. Midwest (1/1/2008-12/31/2022). The first model examined ICU length-of-stay (LOS) using a negative binomial and the second model examined whether a patient was readmitted to the ICU using a logistic regression with each model controlling for PLI utilization and covariates.

RESULTS

Patients with NELP who utilized a PLI in the ICU had 0.87-days longer in the ICU (p < 0.01) and had a 46 % decreased odds of being readmitted to the ICU (p < 0.01) than a comparable patient with NELP who did not utilize a PLI in the ICU.

CONCLUSION

Providing patients with NELP with access to a PLI in the ICU can improve patient outcomes and reduce language barriers.

PRACTICE IMPLICATIONS

These results can provide the justification to potentially increase PLI staffing levels or increase the access to existing PLIs for more patients with NELP in ICUs.

Improving Hospital-to-Home for Medically Complex Children: Views From Spanish-Speaking Caregivers

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) experience increased risk of adverse events during and after hospitalization, and these risks are even greater for CMC whose caregiver has a preferred language other than English. Because many adverse events for CMC may be attributable to communication challenges, understanding caregiver and physician perspectives may help prevent adverse events.

METHODS

We conducted semistructured interviews with Spanish-speaking caregivers of hospitalized CMC and their inpatient attending physicians. Each interview was conducted 24 to 72 hours after hospital discharge. Interviews continued until thematic sufficiency was reached. Interviews were audio recorded, transcribed, and translated verbatim. Investigators independently coded and reconciled codes using constant comparison to develop themes via inductive thematic analysis.

RESULTS

We conducted 28 interviews (14 caregivers, 14 physicians). Three themes were identified: (1) barriers exist in providing language-concordant care in planning for transitions from hospital-to-home; (2) both physicians and caregivers perceived logistical challenges in using interpreters at the point of care; and (3) many caregivers felt uncomfortable asking physicians questions related to their child's medical management because of their language barrier. Participants also offered strategies to improve the transition from hospital to home: (1) empower families to ask questions and take notes, (2) consider the use of medical educators, and (3) improve the ability of hospital-based physicians to follow up with patients after discharge.

CONCLUSIONS

Physicians strive for language-concordant care at each stage of discharge planning. However, unresolved gaps such as the lack of interpreter availability during medical-device education, require attention to promote safe transitions from hospital to home.

Is language a barrier in the management of acute appendicitis?

BACKGROUND

Language preference is a contributing factor for prolonged time from symptom onset to appendectomy within pediatrics, but is poorly characterized in adults. We aimed to investigate associations between language barriers and delays in assessment and treatment for adults with acute appendicitis.

METHODS

In a multiethnic community, patients aged ≥18 years old who underwent appendectomy were identified between January 2017 and August 2022 at a single institution. Negative binomial regression was used to compare interval wait times to imaging, medication administration, and surgical evaluation between patients with limited English proficiency and those who are English proficient.

RESULTS

Of the 1469 patients included, 48% (n = 699) were with limited English proficiency. Average age was higher for patients with limited English proficiency (45 vs 36, P < .001). Most of them were Asian (54%) and without private insurance (65%, P < .001). Symptom duration, incidence of septic shock, and date/time of presentation to the emergency department were similar. Patients with limited English proficiency presented more frequently with gangrenous appendicitis (20% vs 15%, P = .013) but not perforated (23% vs 20%, P = .065). They experienced longer wait times for surgical evaluation (376 vs 348 min, incidence rate ratio [IRR], 1.08; P = .002) but similar times for imaging, and medications administered. After controlling for demographics, triage acuity, and hospital factors, significantly longer wait times for surgical evaluation persisted (IRR adjusted, 1.07; P = .038). There was no significant difference in hospital length-of-stay, postoperative infection, or 30-day readmission rate.

CONCLUSION

Adult patients with limited English proficiency may experience longer wait times for surgical evaluation for acute appendicitis, but this may not result in clinically significant delays in the initiation of treatment.

Biopsychosocial factors associated with pain management in older adults with limited English proficiency

Chronic pain is a prevalent issue among older adults, and effective communication plays a crucial role in accurately conveying the nature of their pain. However, older immigrant adults with limited English proficiency (LEP) encounter significant challenges in expressing the severity and type of pain they experience, creating additional obstacles in their interactions with healthcare providers. This study explored the experience of managing pain among 26 Farsi-speaking older adults with chronic pain. Semi-structured interviews were conducted and data were analyzed using grounded theory methodology. Using the biopsychosocial framework, three main categories of psychological, social, and biological factors arose from data. Depression, stress, sleep disturbances, lack of social support, health literacy, and misdiagnosis or underdiagnosis affected managing pain among older immigrants with LEP. Providing culturally and linguistically competent healthcare providers, particularly in states with a higher number of LEP immigrants, will help maximize the quality of care for patients with chronic pain.

Communicating With Spanish-Speaking Families of Hospitalized Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Hospitalized families who use languages other than English (LOE) for care encounter unique communication challenges, as do children with medical complexity (CMC). We sought to better understand communication challenges and opportunities to improve care of families who use LOE from the perspectives of hospital staff and Spanish-speaking parents of CMC.

METHODS

This qualitative project involved secondary analysis of transcripts from a study on family safety reporting at 2 quaternary care children's hospitals and additional primary data collection (interviews) of staff and parents. Bilingual researchers conducted audio-recorded, semistructured interviews with staff and Spanish-speaking parents of CMC during/after hospitalization. We professionally transcribed and translated interviews and developed, iteratively refined, and validated a codebook. Three independent researchers coded interviews using qualitative descriptive methodology and identified emerging themes through thematic analysis.

RESULTS

We coded 49 interviews (13 parents, 11 physicians, 13 nurses, 6 allied health professionals, 6 leaders). Five themes emerged: (1) assumptions and bias regarding specific groups who use LOE for care, (2) importance of trust and relationships, (3) importance of language-concordant care, (4) workarounds to address communication challenges, and (5) the "double-edged" sword of technology. Participant-suggested strategies to improve communication included increasing interpreter access for parents and staff, optimizing technology use, and minimizing bias and assumptions through training.

CONCLUSIONS

Parents of CMC and staff identified challenges and opportunities related to communicating with hospitalized families who use LOE for care. Solutions to improve communication and safety for these families should be attuned to needs of all parties involved.

Lost in Translation: Impact of Language Barriers and Facilitators on the Health Care of Asian Americans Living with HIV

Language barriers are major obstacles that Asian American immigrants face when accessing health care in the USA. This study was conducted to explore the impact of language barriers and facilitators on the health care of Asian Americans. Qualitative, in-depth interviews and quantitative surveys were conducted with 69 Asian Americans (Chinese, Filipino, Japanese, Malaysian, Indonesian, Vietnamese, and mixed Asian backgrounds) living with HIV (AALWH) in three urban areas (New York, San Francisco, and Los Angeles) in 2013 and from 2017 to 2020. The quantitative data indicate that language ability is negatively associated with stigma. Major themes emerged related to communication, including the impact of language barriers on HIV care and the positive impact of language facilitators-family members/friends, case managers, or interpreters-who can communicate with healthcare providers in the AALWH's native language. Language barriers negatively impact access to HIV-related services and thus result in decreased adherence to antiretroviral therapy, increased unmet healthcare needs, and increased HIV-related stigma. Language facilitators enhanced the connection between AALWH and the healthcare system by facilitating their engagement with health care providers. Language barriers experienced by AALWH not only impact their healthcare decisions and treatment choices but also increase levels of external stigma which may influence the process of acculturation to the host country. Language facilitators and barriers to health services for AALWH represent a target for future interventions in this population.

"They really trust us!": Medical Interpreter's Roles and Experiences in an Integrated Primary Care Clinic

This study describes medical interpreters' experiences with behavioral health (BH) services in a primary care clinic. Focus group data with medical interpreters representing multiple languages was analyzed using hybrid inductive-deductive thematic analysis. Themes related to interpreter roles were: (1) case management, (2) patient-interpreter relationship, and (3) patient-provider liaison. Themes related to barriers and facilitators to interpreter-mediated BH care were: (1) cultural factors, (2) patient-provider interactions, (3) BH-specific considerations, and (4) clinic factors. Results illustrate ways that interpreters directly (e.g., interpreter-mediated services) and indirectly (e.g., relationship building) support care. The interpreter-patient relationship reportedly helped improve patient attitudes and buy-in for BH.

Exploring early discontinuation of mental health outpatient treatment: language, demographics and clinical characteristics among migrant populations in Japan

BACKGROUND

The fast-growing migrant population in Japan and globally poses challenges in mental healthcare, yet research addressing migrants' mental health treatment engagement remains limited.

OBJECTIVE

This study examined language proficiency, demographic and clinical characteristics as predictors of early treatment discontinuation among migrants.

METHODS

Electronic health record data from 196 adult migrants, identified from 14 511 patients who received mental health outpatient treatment during 2016 and 2019 at three central hospitals in the Tokyo-Yokohama metropolitan region of Japan, were used. We conducted multivariable regression models to identify predictors of early discontinuation within 3 months.

FINDINGS

The study cohort (65% women, age range: 18-90 years, from 29 countries or regions) included 23% non-Japanese speakers. Japanese and non-Japanese speakers had similar discontinuation rates (26% vs 22%). Multivariable models revealed younger age (OR=0.97; 95% CI: 0.95, 0.99; p=0.016) and those with a primary diagnosis other than a schizophrenia spectrum disorder (OR=3.99; 95% CI: 1.36, 11.77; p=0.012) or a neurotic, stress-related and somatoform disorder (OR=2.79; 95% CI: 1.14, 6.84; p=0.025) had higher odds of early discontinuation. These effects were more pronounced among the Japanese speakers with significant language-by-age and language-by-diagnoses interactions.

CONCLUSION

Younger age and having a primary diagnosis other than a schizophrenia spectrum disorder or a neurotic, stress-related and somatoform disorder increased vulnerability for discontinuing mental health treatment early in Japanese-speaking migrants but not for migrants with limited Japanese proficiency.

CLINICAL IMPLICATIONS

Understanding language needs within a context of mental health treatment should go beyond assumed or observed fluency. Unmet language needs might increase vulnerability for treatment disengagement among migrants. Targeted clinical efforts are crucial for enhancing early treatment engagement and informing health practices in Japan and countries with growing migrant populations.

Experiences of Providers and Immigrants/Refugees with Health Care: A Meta-Synthesis of the Latin American Context

INTRODUCTION

The experiences of providers and immigrants/refugees related to healthcare in the Latin American context have not yet been aggregated. This study aimed to synthesize the qualitative evidence on this theme.

METHOD

A systematic review of qualitative evidence with meta-synthesis. After identification, eligible studies were evaluated for methodological quality, and information was systematically analyzed.

RESULTS

The sample comprised 26 articles. The meta-theme shows that the experiences of providers and immigrants/refugees are determined by multilevel factors. In a macro-context, these factors involve the vulnerabilities of immigrants/refugees and the healthcare system/model, and in a closer context, they involve the lack of professional training in cultural skills and communication; language barriers; and prejudice/xenophobia. Within healthcare, the relationship is mostly conflictual, asymmetric, and unable to solve problems, leading to negative repercussions for both.

CONCLUSIONS

Managers involved in developing public policies and providers must consider improving the interrelationship between healthcare services and the migrant population.

Language: the ignored determinant of health

Canada is one of the most multicultural countries in the world, with growing numbers of families who do not speak English or French as a first language. However, providing language-concordant services for patients with non-official language preference (NOLP) is not a standardized or measured component of our healthcare system, reflecting the historical marginalization of minority groups in our society. Existing evidence from other countries demonstrates the importance of language as a social determinant of health, and illustrates improved healthcare outcomes for patients with NOLP with the use of medical interpretation. This commentary proposes that a change in our approach to patients with NOLP needs to be accomplished through concerted efforts at the policy, research, and institutional levels in healthcare.

Health Literacy among Korean American Immigrant Women in the USA: Role of Social Support

Health literacy is associated with health behaviors and outcomes. Using Andersen's Behavioral Model of Health Services Use, this study examined the role of limited English proficiency (LEP) and social support for the health literacy of Korean American immigrant women, one of the most affected groups by LEP. Researchers surveyed 232 Korean American immigrant women in a metro area in a Southeastern state, U.S. Health literacy was measured by the CDC Behavioral Risk Factor Surveillance System Questionnaire and the California Health Interview Survey. Participants with better English proficiency and larger social support had higher health literacy. LEP and social support interaction was significantly associated with health literacy, illustrating social support as a buffer that mitigates the negative impact of LEP on health literacy. Community programs that enhance social support through community health advocates or peer educators may increase health literacy and reduce health disparities among Korean American immigrant women with LEP.

Limited English Proficiency and Outcomes in the Intensive Care Unit: An Integrated Review

INTRODUCTION

Language barriers place patients at risk of substandard care. Hospitalized patients with limited English proficiency (LEP) face unique challenges, especially in the intensive care unit (ICU). The purpose of this review is to critique and synthesize quantitative evidence on LEP and ICU outcomes.

METHODOLOGY

Quantitative studies published in English between 1999 and 2022 were queried using intentional terminology.

RESULTS

Searches yielded 138 results, with 12 meeting inclusion criteria. The analysis resulted in the extrapolation of five themes pertinent to outcomes of ICU patients or families with LEP: (a) knowledge deficit relating to conditions and care; (b) lack of language-appropriate care; (c) alienation from care process; (d) decreased confidence and ownership of care; and (e) relationship to clinical quality indicators.

DISCUSSION

Outcomes associated with LEP were largely negative and revealed unmet needs for ICU patients with LEP. More research is needed to improve linguistically and culturally congruent care in the ICU.

Treatment Disparities in Hispanic Patients with Chronic Pain: An Evidence-Based Narrative Review

PURPOSE OF REVIEW

The purpose of this narrative review is to summarize healthcare disparities experienced by Hispanic and Latino/Latinx patients with chronic pain, evaluate the existing literature exploring the specific therapeutic inequities affecting this patient population, and identify gaps in the literature requiring future study.

RECENT FINDINGS

Hispanic and Latino/Latinx patients experience disparities in chronic pain management. They are less likely to be prescribed pharmacologic therapies, including non-steroidal anti-inflammatory drugs and opioids. Hispanic and Latino/Latinx patients are also less likely to receive spinal cord stimulators and may be charged higher costs for them. There are no published studies specifically assessing Hispanic and Latino/Latinx patients' utilization and outcomes from other common interventional pain procedures (e.g., epidural steroid injections, radiofrequency ablation). Limited data suggest non-pharmacologic treatments, such as cognitive behavioral therapy and complementary/integrative health modalities, might have more benefit for this population, potentially because of greater utilization. Hispanic and Latino/Latinx patients experience disparities in chronic pain management. There is a paucity of data available pertaining specifically to pain-related outcomes and the utilization of pain treatment modalities, especially in regard to interventional procedures. Additional research is urgently needed in order to understand the full extent of these disparities and develop solutions to provide more equitable care.

Factors affecting women's participation in cardiovascular research: a scoping review

AIMS

Women are underrepresented in cardiovascular trials. We sought to explore the proportional representation of women in contemporary cardiovascular research and the factors (barriers and enablers) that affect their participation in cardiovascular studies.

METHODS AND RESULTS

Multiple electronic databases were searched between January 2011 and September 2021 to identify papers that defined underrepresentation of women in cardiovascular research and/or reported sex-based differences in participating in cardiovascular research and/or barriers for women to participate in cardiovascular research. Data extraction was undertaken independently by two authors using a standardised data collection form. Results were summarised using descriptive statistics and narrative synthesis as appropriate.From 548 identified papers, 10 papers were included. Of those, four were conducted prospectively and six were retrospective studies. Five of the retrospective studies involved secondary analysis of trial data including over 780 trials in over 1.1 million participants. Overall, women were reported to be underrepresented in heart failure, coronary disease, myocardial infarction, and arrhythmia trials, compared to men. Barriers to participation included lack of information and understanding of the research, trial-related procedures, the perceived health status of the participant, and patient-specific factors including travel, childcare availability, and cost. A significantly higher likelihood of research participation was reported by women following a patient educational intervention.

CONCLUSION

This review has highlighted the underrepresentation of women in a range of cardiovascular trials. Several barriers to women's participation in cardiovascular studies were identified. Researchers could mitigate against these in future trial planning and delivery to increase women's participation in cardiovascular research.

REGISTRATION

The protocol was published on the public Open Science Framework platform on 13th August 2021 (no registration reference provided) and can be accessed at https://osf.io/ny4fd/.

Caregivers with limited language proficiency and their satisfaction with paediatric emergency care related to the use of professional interpreters: a mixed methods study

OBJECTIVES

Communication is a main challenge in migrant health and essential for patient safety. The aim of this study was to describe the satisfaction of caregivers with limited language proficiency (LLP) with care related to the use of interpreters and to explore underlying and interacting factors influencing satisfaction and self-advocacy.

DESIGN

A mixed-methods study.

SETTING

Paediatric emergency department (PED) at a tertiary care hospital in Bern, Switzerland.

PARTICIPANTS AND METHODS

Caregivers visiting the PED were systematically screened for their language proficiency. Semistructured interviews were conducted with all LLP-caregivers agreeing to participate and their administrative data were extracted.

RESULTS

The study included 181 caregivers, 14 of whom received professional language interpretation. Caregivers who were assisted by professional interpretation services were more satisfied than those without (5.5 (SD)±1.4 vs 4.8 (SD)±1.6). Satisfaction was influenced by five main factors (relationship with health workers, patient management, alignment of health concepts, personal expectations, health outcome of the patient) which were modulated by communication. Of all LLP-caregivers without professional interpretation, 44.9% were satisfied with communication due to low expectations regarding the quality of communication, unawareness of the availability of professional interpretation and overestimation of own language skills, resulting in low self-advocacy.

CONCLUSION

The use of professional interpreters had a positive impact on the overall satisfaction of LLP-caregivers with emergency care. LLP-caregivers were not well-positioned to advocate for language interpretation. Healthcare providers must be aware of their responsibility to guarantee good-quality communication to ensure equitable quality of care and patient safety.

Ethical Concerns Regarding the Timing of Written Consent

AbstractObjective: Thorough informed consent requires decision-making capacity, adequate information, lack of coercion, and an appropriate environment. Consent obtained in the preoperative area is hurried, limiting the quality of informed consent and the opportunity for patient reflection, characteristics inconsistent with patient-centered practice. The incidence of obtaining consent immediately prior to surgery is unknown.

METHODS

Consecutive patients undergoing surgery at a single center between 1 June 2021 and 14 June 2021 were identified. Time between consent signature and operating room arrival time was measured. Three surgeons reviewed cases and categorized them as major or not major operations.

RESULTS

78.7 percent (199/253) of patients arriving to the preoperative area the day of surgery signed written consent that day. 99.6 percent (248/249) of anesthesia consents were signed the day of surgery. Spanish as a primary language corelated significantly with consent signing on the day of surgery (p = .04). Race and distance traveled for surgery were not significantly associated with consent signing in the preoperative area. 79.3 percent (157/198) had consent signed within 90 minutes of arrival to the operating room. Among major outpatient cases, 77.8 percent (182/234) had consent signing in the preoperative area.

CONCLUSIONS

This demonstrates routine consent signing in the hurried preoperative setting, suggesting a potential source for improved informed consent. Additionally, language-based consenting disparities, specifically in Spanish, offer opportunity for improvement. The majority of consents were signed the day of surgery, in the preoperative area, and within 90 minutes prior to operating room start time. This offers an opportunity for improved patient-centered care.

Differences in Patient Experiences Among People From Ethnic Minority Backgrounds: A Comparative Analysis of HCAHPS Results

Patients from ethnic minority backgrounds often experience disparities in healthcare quality and outcomes. This study aimed to compare the patient-reported experiences of patients with limited English proficiency (LEP) to general patients in the Australian healthcare setting. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used to evaluate patient experiences from patients in a metropolitan public healthcare network, spanning three hospitals. Level of English proficiency was based on primary language spoken at home. To identify disparities in experience ratings between patients with LEP and the general cohort, independent t-tests were employed. Data was analysed from 2,291 patients, collected over a five-year period (2017-2022), with 490 patients identified as LEP (i.e. speaking a language other than English at home). Statistically significant differences were identified between the cohorts, with LEP patients rating their experiences higher in three areas: doctors listening carefully, doctors explaining in a way they could understand, and quietness at night. Conversely, patients with LEP scored lower in areas regarding nursing respect and responsiveness to call bells. Although patients with LEP had a more positive overall experience, this difference was not statistically significant. The findings indicate potential misalignment between the often poorer health outcomes among people from ethnic minority backgrounds and their experiences in hospital. Additional research is crucial to delve into the unique experiences of ethnic minority patients, including those with LEP, to understand the differences influencing perceptions of care and contributing to disparities in health outcomes.

Strategies Used by Healthcare Systems to Communicate with Hospitalized Patients and Families with Limited English Proficiency During the COVID-19 Pandemic: A Narrative Review

The COVID-19 pandemic disproportionately affected racial and ethnic minorities in the United States, including many with limited English proficiency (LEP). These patients face various communication barriers, including a shortage of available interpreters and the need for masks that exacerbated communication barriers. It is not known how hospitals responded to these unique challenges to providing language services for the large number of patients with LEP during COVID-19. This narrative review assessed literature and lay media to identify strategies utilized by hospitals to communicate with patients with LEP hospitalized during the COVID-19 pandemic. A search of APA PsychInfo, EBM Reviews, Embase, Ovid MEDLINE, Epub Ahead of Print, and Ebsco Megafile initially yielded 61 articles, 6 of which were ultimately included after reviewing abstracts and full texts. The identified interventions, which sought to increase accessibility of language-concordant care, increase accessibility of professional interpretation, and improve family communication and understanding, were described positively, though only one was tested for effectiveness.

When Positive is Negative: Health Literacy Barriers to Patient Access to Clinical Laboratory Test Results

BACKGROUND

Health literacy is a multidimensional set of skills (e.g., narrative, numeracy, digital, medication) that patients need to access and understand health information timely and accurately to make evidence-based informed decisions.

CONTENT

Multiple barriers prevent patients from effectively interacting with health information. The most salient barriers are poor overall health literacy skills and linguistic proficiency in English. As patients prefer direct access to laboratory test results, especially those of routine tests, contextualization and provider-directed interpretation of results are required to foster shared decision-making to address their healthcare issues and improve health outcomes.

SUMMARY

The use of systematic approaches that account for poor health literacy skills and include culturally and linguistically appropriate planning and availability of resources is warranted at individual and population health levels (e.g., human-centered design of patient portals).

The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management

BACKGROUND AND OBJECTIVES

Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance.

METHODS

This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores.

RESULTS

A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85).

CONCLUSIONS

As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.

Communications for US Populations With Limited English Proficiency During Infectious Disease Outbreaks: A Scoping Review

The COVID-19 pandemic has highlighted the need for research about communicating with populations who have limited English proficiency in the United States during infectious disease outbreaks. These populations have experienced significantly worse health outcomes during emergencies, including the COVID-19 pandemic, and evidence-based risk communications are critical to protecting their health. To support improved development of emergency communications for these communities, we conducted a scoping review that examined the extent of research available, with an intent to identify which communications topics are covered in the literature and where research gaps exist. Following the JBI framework, with reporting guided by the PRISMA extension for scoping reviews, 6 electronic databases were systematically searched in October 2022. The inclusion criteria for articles selected were: data collected between 2009 and 2022, published in English, and focused on communications pertaining to emergency infectious disease outbreaks (eg, H1N1 influenza, Zika virus, COVID-19) for populations with limited English proficiency. Of 2,049 articles identified through the search, 31 met the inclusion criteria and were selected for review. We identified major limitations in the evidence base: a majority of studies were conducted only among Spanish speakers or during the COVID-19 pandemic, and most used qualitative or nonrandom samples. Most studies documented basic language barriers in communications, but there was little exploration of more nuanced barriers, such as cultural relevance or social context. Ahead of future outbreaks, more research is urgently needed to examine the information landscapes of populations with limited English proficiency, to inform the development of more effective communications strategies from public health institutions and others.

The Impact of Surgeon Proficiency in Non-English-Speaking Patients' Primary Language on Outcomes After Total Joint Arthroplasty

Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].

Language-Concordant Care: a Qualitative Study Examining Implementation of Physician Non-English Language Proficiency Assessment

BACKGROUND

Language concordance can increase access to care for patients with language barriers and improve patient health outcomes. However, systematically assessing and tracking physician non-English language skills remains uncommon in most health systems. This is a missed opportunity for health systems to maximize language-concordant care.

OBJECTIVE

To determine barriers and facilitators to participation in non-English language proficiency assessment among primary care physicians.

DESIGN

Qualitative, semi-structured interviews.

PARTICIPANTS

Eleven fully and partially bilingual primary care physicians from a large academic health system with a language certification program (using a clinician oral proficiency interview).

APPROACH

Interviews aimed to identify barriers and facilitators to participation in non-English language assessment. Two researchers independently and iteratively coded transcripts using a thematic analysis approach with constant comparison to identify themes.

KEY RESULTS

Most participants were women (N= 9; 82%). Participants reported proficiency in Cantonese, Mandarin, Russian, and Spanish. All fully bilingual participants (n=5) had passed the language assessment; of the partially bilingual participants (n=6), four did not test, one passed with marginal proficiency, and one did not pass. Three themes emerged as barriers to assessment participation: (1) beliefs about the negative consequences (emotional and material) of not passing the test, (2) time constraints and competing demands, and (3) challenging test format and structure. Four themes emerged as facilitators to increase assessment adoption: (1) messaging consistent with professional ethos, (2) organizational culture that incentivizes certification, (3) personal empowerment about language proficiency, and (4) individuals championing certification.

CONCLUSIONS

To increase language assessment participation and thus ensure quality language-concordant care, health systems must address the identified barriers physicians experience and leverage potential facilitators. Findings can inform health system interventions to standardize the requirements and process, increase transparency, provide resources for preparation and remediation, utilize messaging focused on patient care quality and safety, and incentivize participation.

Mammogram perceptions, communication, and gaps in care among individuals with non-English language preference in Oregon and Washington states

This study examined perceptions of and communication about mammography as drivers of gaps in screening among individuals with non-English language preference (NELP). A survey was fielded in fall 2021 in five languages (Cantonese, English, Russian, Spanish, or Vietnamese) to individuals identified using electronic medical records in Oregon and Washington. The analytic sample consisted of 420 respondents with a median age of 61; approximately 45% of respondents identified as Asian, 37% as Hispanic, Latino, or Spanish origin, and 18% as some other race, ethnicity, or origin. Logistic regression models examined associations between screening and perception and communication items. Individuals who believed mammograms are unnecessary when healthy (aRR = 0.72 [0.57, 0.91]) or absent symptoms (aRR = 0.85 [0.72, 1.00]) were less likely to report a mammogram within the past two years (i.e., be current). Having a provider recommend (aRR = 1.27 [1.09, 1.47]) and discuss mammography (aRR = 1.18 [1.05, 1.32]) were associated with a higher likelihood of being current. Few respondents received written or verbal information in their preferred language (35% and 28.3%, respectively). Financial and logistical support, including language services were most frequently identified as types of support needed to obtain a mammogram. Overall, misperceptions about mammography may act as a barrier but communication may act as a facilitator for individuals with NELP. Provider-patient communication could be an effective way to encourage mammography. Culturally-responsive health promotion materials and provider communication, available in patients' preferred language, are needed to combat misperceptions and support ongoing, on-time mammography for NELP patients.

Effective communication with linguistically diverse patients: A concept analysis

OBJECTIVE

Effective communication is essential to providing high-quality healthcare. For linguistically diverse patients, communication remains a barrier to receiving equitable healthcare throughout the globe. It is necessary to examine the concept of effective communication with linguistically diverse patients.

METHODS

The Walker and Avant method was used to analyze the concept.

RESULTS

We define effective communication with linguistically diverse patients as any verbal or written communication between two or more individuals who do not speak the same language that utilizes accurate translation techniques to reach a shared message or understanding, where all parties involved are listened to and actively engaged. The antecedents, attributes, consequences, and empirical referents are mapped.

CONCLUSION

Effective communication with linguistically diverse patients is limited by a lack of access to professional language assistance, structural racism/discrimination, and policy barriers.

PRACTICE IMPLICATIONS

Healthcare workers hold the power to provide language assistance to patients and should therefore receive training in cultural competency, cultural humility, and how to work with professional medical interpreters and language access programs. Institutions should invest in multimodal approaches to provide equitable healthcare to linguistically diverse patients.

Health Disparities for Immigrant Children: Focus on Epilepsy

Although health and health care disparities between immigrant and native-born adult populations in the United States are well documented, the pediatric literature is limited. Data suggest first- and second- generation immigrant children have worse health outcomes when compared with their native-born counterparts because of factors such as socioeconomic status, insurance and language barriers, authorization status, and bias/xenophobia. This article takes a broad look at existing research regarding health barriers for immigrant children, then focuses on the pediatric epilepsy literature to highlight the complex interplay of these disparity factors. Finally, we review the literature on existing interventions, including language concordance, community-driven educational efforts, and broad-scale policy changes that can be used to promote health equity in pediatric epilepsy and beyond. Research gaps are also identified. [Pediatr Ann. 2023;52(10):e373-e380.].