Cultural Language Barriers in Health Care

One important contributing factor to the quality of life of an individual is access to health care and the quality of care they receive. In the United states many are fortunate to have numerous resources for healthcare, but there are still those whose care is inhibited by communication barriers related to culture. “Culture is defined as the totality of socially transmitted behavior patterns, beliefs, customs, lifeways, arts, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making. It is largely unconscious and has powerful influences on health and illnesses.” (Purnell, 2017, p. 2-3). To decrease disparities and increase patient satisfaction a patient’s cultural beliefs and practices should be recognized, respected, and implemented with their care. How is inadequate healthcare related to communication and what actions are being implemented to overcome this barrier?

One of the goals in health care is to provide the safest and best quality of care for patients to promote their quality of life. To provide the best care, the health care team needs access to the best-known practices in health care as well as effective communication between them and the patient. From working five years as a certified nursing assistant directly caring for patients in an Emergency Department I can say there are many important stages of communication involved with treating a patient. Information needed from the patient includes medical history and a description of the symptoms they are experiencing, when those symptoms started, the amount of pain they are experiencing, what kind of allergies they have, and what they have been exposed to that could possibly cause their symptoms. Usually there are tests, procedures, and treatments involved with caring for a patient in the ED and permission is needed from the patient before proceeding with any care. An explanation for all care is necessary for the patient to understand the care they will receive and provide an informed consent. It is especially important to provide an explanation for medications provided, their dose, frequency for administration, and side effects to be aware of. At the end of the patients visit health care instructions for post visit care and follow up are provided. It is very important for all of this information to be accurately understood by both the provider and the patient to avoid dangerous situations for the patient

Misunderstanding healthcare instructions can lead to safety issues (Schyve, 2007, p.360-361). For example, a patient may not understand instructions for how to take their medications and could overdose or take too little of the medication for it to be therapeutic. This is very important for medications such as insulin. Excess insulin can cause potentially life-threatening low blood sugars, or a deficient amount can cause high blood sugars leading to other health issues. A patient may also misunderstand how to take care of themselves while dealing with a chronic condition. For example, a diabetic patient may not understand that they need to be conscientious of their sugar and carbohydrate intake to aid in controlling their blood sugar. A great example of a cultural barrier communication is written in Anne Fadiman’s book “The Spirit Catches You and You fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.” A Hmong infant, Lia, is brought to an American Hospital after experiencing seizures. Lia’s parents did not speak English and Hmong interpreter was not available. The ER doctors performed “vet medicine” and treated the symptoms off illness they found through diagnostic tests. Lia’s parents could not communicate she had been having seizures. Every time Lia was brought into the hospital, she was treated for illnesses such as pneumonia, which was caused by aspiration during a seizure. It wasn’t until Lia’s parents brought her in while actively seizing that she was diagnosed with epilepsy and the physician understood it had been missed in the previous ER visits. Also due to cultural beliefs and the language barrier, the parents did not understand the importance of being consistent with her seizure medication to suppress the seizures. The parents believed no one should be on a medication forever and they did not like the side effects Lia experienced. They believed the medication was making her sicker so they discontinued giving some medications while under dosing or over dosing the others. Due to the inconsistency, Lia’s seizures got worse and eventually caused brain damage that made Lia a “vegetable,” (Fadiman, 2012).

There are several main factors contributing to communication as a barrier in health care: unproficiency in the common language, inadequate health literacy, inadequate reading level, and different meanings of a word to different cultures. Language becomes a barrier when it is assumed there is proficient understanding of a common language. This can occur when the patient states they understand an adequate amount of the common language or when the provider believes they are proficient in the patient’s language. Often times a patient will use a family member as their interpreter, but the family member is not proficient enough to translate medical terminology. Using a family member, such as a child, as an interpreter can inhibit the patient from sharing sensitive information such as sexuality, drug and alcohol misuse, and domestic violence (Purnell, 2014). Cultural differences in language interpretation present as a barrier due to different meanings or understandings of a word in different cultures. Low health literacy can present due to language and cultural barriers, but often within groups of people of the same culture. Health literacy also involves the patient’s ability to read and write. Often a provider will assume the patient is health literate if they speak the same language and are of the same culture. A patient can feel embarrassed by their lack of knowledge and my not communicate their lack in understanding, so the provider is unaware. This assumption leads to inadequate understanding of health care by the patient (Schyve, 2007, p. 360-361). Patient’s may also be at a low reading level and can’t read the instructions on their care instructions or the directions on the medication bottles. This can also be embarrassing for the patients to admit to, so the health care team can be unaware. The patient may also be very proficient with reading, but only in their own language, however they could receive instruction in English, which they can’t read. All of these issues encountered with communication barriers lead to inadequate health care for the patient and increases cost as well as health risks.

According to research conducted by the Center for Immigration Studies, one in five U.S. residents speak a foreign language at home. That is a record of 61.8 million people. The research also concluded that of those who speak a foreign language, 25.1 billion (41 percent) reported to the Census Bureau they speak English less than very well (Camarota, Zeigler, 2014). Roughly eight percent of America’s population is at risk for experiencing communication issues in health care. Some studies show an association between a language barrier and health care related issues such as preventative care and screening, mental health care, pain and symptom management, chronic disease management, informed consent, and medication errors.

For those who have limited English skills knowing what health care services are available to them and making an appointment can prove challenging. Many online, over the phone, or print resources are usually available in English or Spanish. Limited skills can also prevent a person from picking up health information from places most of us learn our information such as the newspaper, advertisements, T.V., or radio. Lack of English proficiency is correlated with lack of knowledge about stroke and heart attacks (Chow et al., 2008; DuBard et al., 2006), and lack of information regarding cancer signs and symptoms (Fitch et al., 1997).

According to Jacobs, Shepard, and Stone those whose primary language is not English are less likely to use a source of primary care and less likely to receive preventative care (Jacobs, Shepard, Stone, 2004). One study found that infants of parents whose primary language was not English were half as likely to receive all recommended preventive care visits compared with infants of parents whose primary language was English (Cohen & Christakis, 2006). Language barriers have been demonstrated to result in lower participation in cancer screening programs: breast cancer screening, cervical cancer screening, and colorectal cancer screening (Alexandraki & Mooradian, 2010; Ayanian et al, 2005; Fang & Baker, 2013).

Mental health care relies heavily on language to appropriate treat mental health diseases. Older generations of immigrants with limited English-speaking skills present with high rates of mental health disorders but are also less likely to seek help. (Kim et al., 2011). Managing a patient’s pain is also an area effected by language barrier. Patients who unable to effectively communicate the amount of pain they are in are less likely to have it managed effectively. Jimenez reported obstetrical patients who receive interpreter services are more likely to report better pain control and treatment than those who did not receive an interpreter (Jimenez et al., 2014).

One area of concern with language barriers is chronic illness management because the patient will experience symptoms either longer term or for the rest of their life. Leaving them unmanaged can further exacerbate the disease and possible lead to preventable worsening health conditions or death. Using diabetes as an example, there is a lot of important information involved with managing this chronic illness. Knowledge of diabetes management includes knowledge of diet and exercise, both of which aid in lowering blood sugars. A diabetic patient must also know how to check their blood sugars as well as how often to monitor for elevated or low blood sugars that could lead to more health care issues or life-threatening situations. According to studies about language barriers and diabetes, all of these areas are shown to be deficient when compared with English speaking patients (Detz et al., 2014; Fernandez et al., 2011; Karter et al., 2000).

Informed consent for care or a procedure is very important in health care. The provider needs permission from the patient who fully comprehends all aspects of the care or procedure they are receiving. A procedure such as surgery requires that the surgeon explains the reason for the surgery, the steps of the surgery, medications being used, as well as the post-operative symptoms and potential risks. A patient with a language barrier cannot give informed consent if they do not understand everything the surgeon is saying. A study by Schenker showed non English-speaking patients were less likely to have documentation of informed consent for invasive procedures such as surgery (Schenker et al., 2007). Another study showed it was unknown if patients with limited English skills who were not provided an interpreter received adequate information for them to be considered informed (Hunt & de Voogd, 20070).

A safety concern for patients with a language barrier involves medication errors. Patients without interpreter services are at risk for misunderstanding medication administration instructions, will less likely take their medications consistently as directed, will have inadequate symptom management, and are at risk for further complications (Dilworth et al., 2009). In one study conducted, evidence showed Spanish speaking patients were more likely to experience a dosing error than English speaking patients (Samuels-Kalow et al., 2013). ?

Bibliography

Fang, D. M., & Baker, D. L. (2013). Barriers and facilitators of cervical cancer screening among women of hmong origin. Journal of Health Care for the Poor and Underserved, 24(2), 540- 555. doi:10.1353/hpu.2013.0067; 10.1353/hpu.2013.0067

Fernandez, A., Schillinger, D., Warton, E. M., Adler, N., Moffet, H. H., Schenker, Y., . . . Karter, A. J. (2011). Language barriers, physician-patient language concordance, and glycemic control among insured latinos with diabetes: The diabetes study of northern california (DISTANCE). Journal of General Internal Medicine, 26(2), 170-176. doi:10.1007/s11606-010- 1507-6

Hunt, L. M., & de Voogd, K. B. (2007). Are good intentions good enough? informed consent without trained interpreters. Journal of General Internal Medicine, 22(5), 598-605. doi:10.1007/s11606-007-0136-1

Jacobs, A.E., Shepard, D.S., Suaya, J.A., Stone, E.L. (2004). Overcoming languages in healthcare: Cost and benefits of interpreter services. Am J Public Health, 94(5), 866-869.

Jimenez, N., Jackson, D. L., Zhou, C., Ayala, N. C., & Ebel, B. E. (2014). Postoperative pain management in children, parental english proficiency, and access to interpretation. Hospital Pediatrics, 4(1), 23-30. doi:10.1542/hpeds.2013-0031; 10.1542/hpeds.2013-0031

Karter, A. J., Ferrara, A., Darbinian, J. A., Ackerson, L. M., & Selby, J. V. (2000). Self-monitoring of blood glucose: Language and financial barriers in a managed care population with diabetes. Diabetes Care, 23(4), 477-483.

Kim, G., Aguado Loi, C. X., Chiriboga, D. A., Jang, Y., Parmelee, P., & Allen, R. S. (2011). Limited english proficiency as a barrier to mental health service use: A study of latino and asian immigrants with psychiatric disorders. Journal of Psychiatric Research, 45(1), 104-110. doi:10.1016/j.jpsychires.2010.04.031

Purnell, L.D. (2014). Guide to culturally competent health care (3rd ed.). Philadelphia, PA: F.A. Davis Company.

Schenker, Y., Wang, F., Selig, S. J., Ng, R., & Fernandez, A. (2007). The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. Journal of General Internal Medicine, 22 Suppl 2, 294-299. doi:10.1007/s11606-007- 0359-1

Schyve, P.M. (2007). Language differences and a barrier to quality and safety in healthcare: The joint commission perspective. J Gen Intern Med, 22, 360-361. doi:10.1007/s11606-007-0365-3 

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