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Breaking Down the Language Barrier

Wheel the patient out of their hospital room, use the elevators to take them to the first

floor, make a stop at the discharge pharmacy to pick up any meds if necessary, and transport

them out to their car. It was just a normal patient discharge, not unlike the hundreds I had taken

before during my two years as a Kaiser Permanente hospital volunteer. However, when asking

the patient if they needed to visit the discharge pharmacy, I noticed them struggling to convey

their response, mixing in words from Spanish. Such a situation was not common, yet still

something I had encountered before. Thus, using whatever knowledge I had gained from my first

five years of Spanish, I created a basic dialogue between me and the patient, hoping that our next

stop would have a medical professional fluent in Spanish. Unfortunately, that was not the case.

The pharmacist first asked if the patient had any allergies, to which the patient’s confused face

turned towards me. “¿Alergias?” I prompted, and the patient immediately responded “no.”

“Take three tablets a day,” the employee stated, looking directly at me. Not wanting to be

responsible for the important task of conveying the instructions regarding the medications, I

informed the employee that I was not fluent and another pharmacist, speaking both Spanish and

English came to the patient's assistance. Nevertheless, I was dismayed when the pharmacist

could only speak a fragmented form of Spanish, about as fluent as me and my peers in Spanish 2.

Wheeling the patient out to his car, I was left wondering if he had truly understood the

instructions: would he be able to care for himself outside the hospital walls with only a set of

broken instructions and a English label around his pill bottle. Soon, I began to notice the

differences in the patients’ experiences when the doctor could converse with them in their native

language, versus when they spoke different languages. While shadowing a family care physician,

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an elderly lady’s son attempting to get her signed up for her first medical examination in

America after she immigrated from India. The doctor’s ability to directly converse with her in

Hindi, instead of talking to the son who in turn would translate the questions, increased the

patient’s comfort level, ensured that the patient and the doctor were understanding each other

clearly, and reduced the potential for any medical errors. The discrepancies in these medical

situations led to my question: ​What challenges regarding health literacy do non-English

speakers face when navigating the U.S. healthcare system, and what action can be taken to

combat these struggles?

A reduced rate of health literacy, defined as "the degree to which individuals have the

capacity to obtain, process, and understand basic health information and services needed to make

appropriate health decisions” by the Institute of Medicine report, Health Literacy: A Prescription

to End Confusion, is often a result of a lack of complete communication caused by the language

barrier. When patients are unable to understand the information being delivered to them by their

nurse or doctor, they cannot make well-informed decisions regarding their health. Additionally,

this is a continuous cycle. While a lack of effective communication is a barrier to health literacy,

“low health literacy is [also] a barrier to effective communication” (Schyve). Unable to

understand the basics of medicine, patients with low health literacy are powerless to voice any

concerns or ask for clarifications when provided with health services. The combination of poor

communication and low health literacy creates a dangerous situation for patients that has been

shown to lead to “lower health status, increased rates of hospitalization (Baker et al., 1997; Baker

et al., 1998), and poor understanding of health conditions and diseases (Williams et al., 1998;

1998a)” (Bowen). A lack of health literacy poses a greater threat when patients are discharged

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from the hospital, while being entrusted with their own care at home. Not being well-versed in

medical practices, non-English speakers have difficulty understanding discharge instructions and

often report errors in taking medication due to prescription labels that are difficult to decipher.

From the moment these patients are introduced to the U.S. healthcare system, they are

immediately at a disadvantage. The difficulty in communication results in disparities between the

information conveyed by the medical staff and the details understood by the patients.

Furthermore, the language barrier that hinders them from pursuing answers to their questions

leads to inadequate knowledge of medical practices and is detrimental to their overall prognosis.

Patients facing the language barrier are often less satisfied with the provided services,

leading them to be less likely to adhere to and comply with the prescribed treatment. Trust is

vital in patient-doctor interactions. If the patient is not convinced that the doctor is

knowledgeable about their medical concerns, they may begin to doubt not only the doctor, but

the entire healthcare system as well, making it more likely for them to understand their

prescribed medications and further instructions regarding how to proceed to be nothing more

than suggestions. In a study done by A. Manson to test for a correlation between language

concordance and asthma patient compliance, as well as emergency room use, it was found that

“patients with a language-discordant physician were less likely to have therapeutic blood levels

of bronchodilator medication, and more likely both to miss office appointments, and to make an

emergency room visit” (Bowen). Put in simpler terms, monolingual Spanish speakers whose

doctors were only able to speak little or no Spanish failed to take medication as instructed,

displayed as lower levels of the medication in the bloodstream than was necessary to be

effective. Additionally, it was more common for these patients to fail to attend their

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appointments, requiring them to later make an urgent trip to the emergency room for a more

severe medical issue. Unable to grasp the immense amount of instructions thrown at them, the

monolingual patients were at risk of more critical, acute episodes, which starkly contrasted the

control group, where monolingual Spanish speakers were assigned to physicians fluent in

Spanish. Furthermore, in another study, it was reported that “the lack of explanations regarding

potential side effects was reported by patients to have a negative impact on their compliance with

medication” (David). When discussing the topic of medicine it is impossible to avoid the

emotional factors that arise throughout the process of seeking out necessary care. People who are

fearful of medications and hospital procedures are likely to doubt doctors, and if not provided

with thorough information, will fail to comply with medications out of trepidation for the

possible negative outcomes. Hence, when told about the positive and negative aspects of a

medication, patients are most comfortable with the knowledge that there is transparency between

them and the physician, making it more likely for them to follow the prescribed medical

regiment. Patients given clear directions regarding their medication, such as being told how

many times to take their medication per day instead of by hourly intervals were found to be more

likely to abide by the instructions (David). Thus, when non-English speakers do not understand

the medical procedure or the routine they are expected to follow, they have lower rates of

compliance, which increases their risk for more serious illnesses. Hence, less satisfaction with

healthcare services indirectly leads to lower health literacy as patients cannot obtain complete

information regarding their health and their treatment plan, which can potentially lead to more

severe consequences.

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Additionally, staff that lack knowledge of proper medical terminology and have limited

translation capacities hinder effective communication. Interpreter services are common

throughout most U.S. hospitals. However, in order to reduce costs, many hospitals limit the use

of professional interpreters significantly, while increasing their dependence on ad hoc

interpreters such as “family members, friends, untrained members of the support staff, and

strangers found in waiting rooms or on the streets” (Flores). While these interpreters can be

successful, they also pose a risk to the patients as “many times the accompanying friend or

relative of the Spanish-speaking patient may be well-educated but nevertheless unable to

translate the very technical and usually very intimate questions and answers between doctor and

patient” (Leone 154). Professional medical interpreters are trained to speak another language for

the purpose of interpreting for hospitals, which causes them to be well-versed in the proper

terminology for medical conditions. This allows for near perfect translation from English to the

patient’s language of comfort. Nevertheless, on the other hand, the patients have not been trained

in medical terminology, which means the interpreters must know the formal language of

medicine while also being able to explain the information using common terms. This often

serves as a barrier to health literacy, as the patient is unable to gain a complete understanding of

their health due to differences in vocabulary. When asked about the challenges that arise when

treating patients that do not speak English fluently or prefer another language, Juliana Rodriguez,

a current oncology nurse who is heavily involved with the John Muir Mobile Health Clinic,

providing basic health services to underserved communities with high Hispanic populations,

admitted that “ some patients might not know the terminology form… I have noticed that when

the translator is translating certain things to them, they are not exactly sure what that means, so

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we have to describe it or explain it in a different way where they’re able to understand.” As a

QEI, or a Qualified Employee Interpreter, Ms. Rodriguez is often assigned to Spanish speaking

patients. Her ability to speak another language allows her to ensure the patients understand the

large amounts of information they are given and have all their questions answered. Therefore,

having a bilingual workforce improves patient-doctor communication and can aid non-English

speakers in acquiring their necessary health resources.

Patients that do not speak English are typically more comfortable speaking with a nurse

or a doctor in their primary language, which makes it easier to establish trust within the

relationship. Being in a hospital setting is naturally overwhelming. As explained by Isis Morales,

the LVN, or Licensed Vocational Nurse for the John Muir Mobile Health Clinic, “Even for

somebody who doesn't… need translation… you go to a visit, you're nervous, you're hearing all

this information… you have all these questions… you forget to ask because you're overwhelmed

with all of what's going on and… you leave not understanding everything.” For people not

involved with the medical field, hospital visits are daunting as they include extensive amounts of

information that is difficult to understand. Nevertheless, most English speaking patients feel

comfortable asking questions for clarification, while non-English speakers are hesitant to

communicate with medical professionals who cannot converse in the same language. In a study

done in Saudi Arabia to test how the nurse-patient language barrier impacted patients’

satisfaction, “half of [the] patients [believed] that NASNs [non-Arabic speaking nurses] might be

more susceptible to making errors during care, and almost 70% felt uncomfortable dealing with a

nurse who [could not] communicate in the same language...Seventy-five percent of patients felt

the Arabic speaking nurse was more capable of showing empathy” (Khathami). A lack of trust

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between the patient and the healthcare professionals can deter the patient from seeking out

answers or more details regarding their ailments. Furthermore, the patient may also be tentative

to share certain information regarding their symptoms or issues during their treatment, which

could result in an incorrect diagnosis. Overcoming the language barrier allows patients to be

comfortable sharing personal information with nurses and doctors, decreasing the number of

medical errors and enhancing the overall patient experience.

Now, it is imperative to find a solution to the issue of the language barrier by optimizing

the utilization of interpreting services, while expanding the bilingual workforce in the healthcare

field. The language barrier is a larger issue than it appears, especially within the United States, a

place that serves as a melting pot of different ethnicities. To begin solving this problem, the

healthcare field must begin with the following:

[They] need to develop a deeper understanding of communication issues that come with

diverse patient populations and to distinguish health literacy challenges from language

and cultural barriers… [They] also need to test and learn the benefits and drawbacks of

different ways to deploy or use interpreters effectively and ways to ensure quality and

safe health care for every patient without incurring more cost than value (Partida)

Economics will always be central to healthcare. Despite the altruistic nature of the field, it is also

a business that wants to increase profits while minimizing costs. However, the healthcare field

has the resources, they simply need to use them more efficiently. While sharing her experience

with monolingual Spanish speakers, Ms. Morales explained how “most hospitals and clinics do

have some type of translation system... some just don't utilize it or don't know they have it, but

it's really sad to hear that they have these struggles [and] it’s more of an emergency and they get

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ignored or they just go home because they felt like they were being ignored.” By failing to utilize

the interpreter services, hospitals are wasting their money and extra resources when the patients

are later admitted for more serious illnesses. While the language barrier reduces health literacy

rates, it also reduces the ability to access basic care, which is a larger, more threatening problem.

However, the solutions are simple. As Ms. Rodriguez described, she has worked with patients

who do not “feel comfortable telling a doctor certain things about what's going on [with] them

over the phone or via video with an interpreter, versus them communicating with [her] and…

relaying the message... if you get the same person all the time, you build a relationship with them

and then you feel more comfortable.” Instead of having the translation services be online,

hospitals should provide in person interpreters to form close bonds with the patients, in order to

encourage them to ask questions about their health and increase their health literacy.

Additionally, to reduce the cost of having constant interpreting services available, more bilingual

health professionals should be hired, as they serve multiple purposes, saving the hospital any

extra costs. The infrastructure to support non-English speakers through the healthcare system

already exists, it is now necessary to make use of the resources to best assist the underserved

community.

The language barrier causes a consistent lack of effective communication, which is

detrimental to a patient’s health as it leads to lower levels of compliance with medical

instructions, a decreased understanding of diagnosis and treatment plans, and a lack of trust and

comfort being established between the patient and the doctor. Non-English speaking patients are

at a significant disadvantage as they are unable to vocalize their concerns to the health

professionals tasked with their care, causing a misdiagnosis or even a missed diagnosis. The

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growing questions that remain unanswered result in patients being skeptical of the healthcare

system and reluctant to follow the instructions they have been given. In order to improve the

healthcare system for non-English speakers, hospitals must improve their interpreter services and

utilize them whenever possible. While online interpreter services are effective, the personal

connection formed when speaking to someone physically present is critical to establishing the

patients’ confidence in the healthcare system in order to ensure they receive the treatment they

require. The healthcare field should also prioritize hiring those who are bilingual to limit extra

expenditures and guarantee accessible translation services. Providing interpreters from the initial

encounter is important as it reduces the chance that the patient will feel ignored and choose to

remain distant from medical professionals until a true emergency occurs. Populations that are not

fluent in Spanish are traditionally underserved, and the language barrier only adds to their

struggle to access basic healthcare services. With over fifty percent of immigrants speaking

English less than “very well” (U.S. Census), we must do better.

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Works Cited

Bowen, Sarah. ​Language Barriers in Access to Health Care​. Health Canada, 2001. Accessed 10

Mar. 2020.

David, R A, and M Rhee. “The Impact of Language as a Barrier to Effective Health Care in an

Underserved Urban Hispanic Community.” ​The Mount Sinai Journal of Medicine, New

York,​ U.S. National Library of Medicine, 1998, www.ncbi.nlm.nih.gov/pubmed/9844369.

Accessed 1 March 2020.

Flores, Glenn. “Language Barriers to Health Care in the United States.” ​New England Journal of

Medicine​, vol. 355, no. 3, 2006, pp. 229–231., doi:10.1056/nejmp058316. Accessed 10

Mar. 2020.

“Health Literacy.” ​Official Web Site of the U.S. Health Resources & Services Administration,​ 13

Aug. 2019, www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/index.html.

Accessed 15 Mar. 2020.

Khathami, Ali M., et al. “The Effect of Nurse-Patient Language Barrier on Patients’

Satisfaction.” ​Saudi Medical Journal,​ vol. 31, no. 12, 18 Oct. 2010, pp. 1355–1358.

Accessed 10 Mar. 2020.

Leone, Elizabeth A., et al. “Language as a Barrier to Health Care.” ​Spanish Language Use and

Public Life in the United States,​ by Elías-Olivares Lucía et al., Mouton, 1985, pp.

153–163. Accessed 1 Mar. 2020.

Morales, Isis. Licensed Vocational Nurse. Personal Interview. 9 Mar. 2020.

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Partida, Yolanda. “Addressing Language Barriers: Building Response Capacity for a Changing

Nation.” ​Journal of General Internal Medicine,​ vol. 22, no. S2, 2007, pp. 347–349.,

doi:10.1007/s11606-007-0367-1. Accessed 10 Mar. 2020.

Rodriguez, Juliana. Licensed Vocational Nurse. Personal Interview. 24 Feb. 2020.

Schyve, Paul M. “Language Differences as a Barrier to Quality and Safety in Health Care: The

Joint Commission Perspective.” ​Journal of General Internal Medicine,​ vol. 22, no. S2,

2007, pp. 360–361., doi:10.1007/s11606-007-0365-3. Accessed 10 Mar. 2020.

US Census Bureau. “Close to Half of New Immigrants Report High English Speaking Ability.”

The United States Census Bureau,​ 15 Sept. 2014,

www.census.gov/newsroom/press-releases/2014/cb14-105.html. Accessed 17 Mar. 2020.

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