Improving health outcomes for patients and families with preferred language other than English or French (PLOEF)

Abstract

Equitable care considers the unique needs of an individual—including social determinants of health such as language, race, and gender. Health equity and providing equitable care are considered fundamental to medicine, however, in practice there continues to be significant gaps to providing equitable care. There is a growing body of research on health care disparities, such as research on patients and families who have a preferred language other than English or French (PLOEF), who have worse health outcomes. Language barriers have been associated with increased risk of hospital admission, increased risks of misdiagnosis, poorer patient understanding of and adherence to prescribed treatment, lower patient satisfaction, and increased risk of experiencing adverse events. This commentary aims to examine issues faced by patients and families with PLOEF, particularly among hospitalized children and youth, and propose how the paediatric community can work to improve their care and health outcomes.

The following patient vignette is a composite of various patient cases encountered during paediatric residency.

PATIENT VIGNETTE

‘Beau’, a 13-year-old non-verbal male with medical complexity, was admitted to the general paediatric ward with oxygen desaturations of unknown etiology. During the first couple of nights of his admission, he continued to require oxygen overnight for unclear reasons. The team had initially obtained a limited history using Language Line during the admission amidst a busy ward service. During rounds, Beau’s mother would smile politely—telling the team that she trusted their decisions for Beau’s care. During the late afternoon on the second day of admission, the resident sat down with Beau’s mother, along with an interpreter, to better understand Beau’s story.

Beau’s family were refugees and had been living in Canada for a little over a year. During the conversation, the resident learned Beau had been diagnosed with obstructive sleep apnea a few months ago but had not been able to get access to CPAP. Beau’s mother recalled a specialist appointment that occurred without an interpreter leaving her confused about next steps. Beau’s mother also noted Beau had back pain and that although Beau would not communicate this, she noticed him grimacing with transfers in and out of his wheelchair. She also discussed housing and financial concerns.

A major focus of the admission thus became working with Beau’s mother to connect the family with the services Beau needed. Beau’s story gave the inpatient team a glimpse into the many cracks in our health care system that vulnerable patients can fall through. In particular, Beau’s story highlights the additional challenges that language barriers can present for patients and their families.

BACKGROUND

The World Health Organization defines health equity as, “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” (1). With the welcomed emphasis on equity, diversity, and inclusivity in the medical field, it is critical that we evaluate how structural inequities contribute to health outcome disparities. Patients with limited English proficiency (LEP) can be defined as individuals who self-identify their English language skills as less than ‘well’ (2). We note the movement to consider alternative terms to LEP as this term can have negative connotations. The ethnocentric notion of ‘English as a primary language’ and a deficit-oriented approach to naming the issue are examples of concerns raised (3). Furthermore, this term is mostly used in an American context. We will use the term preferred language other than English or French (PLOEF), given this piece is focused on the Canadian context, acknowledging that there are many terms used in the literature and that terminology continues to evolve. As most of the literature currently uses alternate terminology, when citing other studies, we will employ the terminology used within that study.

Canadian census data indicates 12.7% of Canadians predominantly speak a language other than French or English at home (4)^. Over 24% of Canadians report a mother tongue other than English or French (5). In Montreal, almost 2% of the population is estimated to not speak English or French (5). In Toronto, a 2018 report estimated that 130,000 Torontonians did not speak any English (6). At our large tertiary centre, interpreter services logged over 25 000 interpreted clinical interactions in 2020. The most common languages requested were Arabic, Mandarin, Cantonese, Spanish, Tamil and Urdu. This highlights the cultural and linguistic diversity that exists in many Canadian settings. Thus, studies with limited cultural and linguistic diversity (e.g., focused on one non-dominant language) may not be entirely generalizable to a Canadian setting.

OBLIGATION TO PROVIDE TO EQUITABLE CARE

The Charter of Rights and Freedoms and the Canadian Multiculturalism Act are designed to protect Canada’s cultural diversity. In Ontario, the Ontario Human Rights Code protects the rights of all Canadians regardless of cultural or linguistic background. Importantly, the Canada Health Act describes the objective to “facilitate reasonable access to health services without financial or other barriers (7). However, language-discordance in health care settings is a significant barrier to equitable access of care.

While the passage of the Official Languages Act in 1969 entrenched in law the rights of both English and French speakers to a range of services in their first language (8) there is no legislation mandating provision of language services other than English or French, except for cases of criminal proceedings (9). Francophones living outside of Quebec (and some Anglophones living in Quebec) may also face language barriers to receiving care in their first language, depending on their location of residence (10).

In 1997, in a landmark ruling, the Supreme Court of Canada, determined that hospitals were obligated to provide interpreter services for Deaf patients (11). The ruling noted: “where sign language interpreters are necessary for effective communication in the delivery of medical services, the failure to provide them constitutes a denial of s. 15(1) of the Charter….” The ruling also emphasized that “effective communication is an indispensable component of the delivery of a medical service.” This ruling sets an important precedent and highlights our obligation to remove other language barriers in health care delivery.

DEFINING THE PROBLEM: COMMUNICATION ISSUES AND THE EFFECTS ON PAEDIATRIC PATIENTS AND FAMILIES WITH PLOEF

Communication issues are known to contribute to and directly cause serious medical errors (12). These issues are more prevalent in patients and families with LEP, who have been shown to be at increased risk of hospital admission, being misdiagnosed, and reporting lower patient satisfaction (13,14). Khan et al. reported that hospitalized children of parents with limited comfort with English were twice as likely to experience harm due to medical care (14). Communication barriers may prevent a family from asking questions and pointing out errors. Interpretation errors, possibly related to ad hoc interpreter use, with negative patient safety consequences have been identified in paediatric settings (15). Given this knowledge, we need to develop solutions to provide equitable care for all children, regardless of language. Recently a James Lind priority study in paediatric hospital care conducted by the Pediatric Inpatient Research Network (PIRN) identified, “What methods of communication are most effective between patients, caregivers and health care providers on a general paediatric inpatient unit?” (16), as the second most important unanswered research question in Canadian paediatric hospital medicine, with many points raised centering on patients and families with PLOEF.

THE INPATIENT HOSPITAL CARE SETTING

Interpretation errors and language barriers may be even more prominent in the inpatient setting, due to the severity of illness and additional challenges such as multiple healthcare providers needing to communicate complex information. Barriers to interpreter use include difficulty accessing interpreters, time limitations, and lack of education regarding how to work with interpreters. Key events such as admission, discharge, medication reconciliation, procedural consent, and rounds are just some of the interactions of which it is critical to have professional interpreter services. Patients and families should have an equitable opportunity to understand, question and participate in care while in hospital, thus any interactions that may occur which a patient and their family may not understand (such as consent discussions) should be conducted with interpreter support.

Unfortunately, studies have noted that many clinical interactions in hospital settings occur without an interpreter (17). A study of resident physicians in the early 2000s noted that even though they perceived their communication with patients with PLOEF to be suboptimal, they rarely used professional interpreters. Instead, they often relied on their less-than proficient skills, employed other colleagues as interpreters, or minimized communication (17). A recent qualitative study found that physicians view medical interpreters as serving multiple roles including cultural brokers, therefore it is important to understand whether interpreter use patterns, training, and family understanding and desires of interpreter roles are in alignment (18).

TAKING STEPS TO IMPROVE CARE FOR PATIENTS AND FAMILIES WITH PLOEF

The paediatric community has a responsibility to take strategic steps to improve hospital health outcomes for patients and families with PLOEF.

Firstly, in a Canadian context, we need a common definition of patients and families with PLOEF and standardized ways to measure and report data. Ensuring accurate data to guide interventions is critical to addressing this health disparity and improved data collection must be an urgent priority. Hospitals currently lack data on how many families require interpreter services. Secondly, there is a need to further understand the extent of health disparities experienced by patients and families with PLOEF specifically in the Canadian context. An analysis of care practices among Canadian paediatric inpatient centres regarding patients and families with PLOEF, possibly through the PIRN could serve as an initial needs assessment and build a community of interest dedicated to this work.

Thirdly, there is a gap in the current body of literature on understanding the lived experience of paediatric patients and families with PLOEF who have been admitted to inpatient paediatric care units. Studies that probe patients and families regarding how their experiences can be improved would provide important insight to prioritize areas of research and reform. We must ensure this work is done in partnership with patients and families in a culturally safe manner. Systems innovators and researchers must be open to approaching issues using new principles, practices, and theory such as anti-racism and anti-oppression frameworks. Increased virtual care poses another setting where we must consider unique effects for patients and families with PLOEF.

Fourthly, from a funding perspective, increased resources to ensure that interpreter services are more easily accessible are critical. Healthcare information, such as visit summaries, should be available in multiple languages and professionally translated. Thoughtful consideration should be given to most effectively utilize EMR and language translation technology services, recognizing the limits of these technologies. If they are employed after participatory research is conducted with populations with PLOEF, it is more likely they will become significant assets. All healthcare providers should receive education on interpreter use and best practices in providing care of patients with PLOEF. These steps represent a few ways we can begin strategically addressing health disparities experienced by patients and families with PLOEF in the paediatric setting. Having access to interpreters is not only a matter of providing medically and culturally safe care—it is also critical to honour the humanity and dignity of our patients. As paediatricians, we have the obligation to ensure we are providing equitable care. For the sake of our patients, like Beau, let us take concerted, collaborative efforts to do so.

FUNDING

There is no funding to declare.

POTENTIAL CONFLICTS OF INTEREST

VD reports the receipt of a grant/contract from Leong Centre Studentship and the PSI Foundation, and is a Board member, Canadian Society Physician Leaders and a Council member, Royal College of Physicians of Surgeons of Canada. SM reports receiving grants from Leong Centre Studentship, Physician Services Foundation and CIHR as well as participation on a Data Safety Monitoring Board/Advisory Board for the NIH Eliminating Monitoring Overuse Trial; SM is also Senior Deputy Editor, Journal of Hospital Medicine.