Abstract
In the United States, the growing population of older adults with limited English language proficiency (LEP) faces profound health care disparities. Previous research on vaccination of older adults has been based on self-reported data, without clinical verification. We compared pneumococcal vaccination rates between a patient group with LEP and a group of English speakers in an older community-dwelling population. A population-nested matched cohort of participants age 65 years and older was identified in the state. Patients with LEP were identified through an electronic alert within the electronic health record, designed to determine the need for an interpreter. Patients were matched 1 to 1 for age, sex, and Charlson comorbidity index. We used conditional logistic regression for the final analysis. In total, 24,052 patients were identified as older patients (mean [SD] age, 74 [7] years). Of them, 617 patients (2.6%) had LEP. The most common primary languages were Somali (24%), Vietnamese (15%), and Spanish (13%). We found lower rates of vaccination with 13-valent pneumococcal conjugate vaccine (PCV13) in the LEP group compared with English speakers (62% vs 77%; odds ratio [OR] [95% CI], 2.07 [1.61–2.66]; P<.001). Results were similar for 23-valent pneumococcal polysaccharide vaccine (PPSV23) (60% vs 75%; OR [95% CI], 1.97 [1.54–2.51]; P<.001). These data are suggestive that older adults who required a language interpreter during health care encounters were less likely to be vaccinated with PCV13 and PPSV23 than older adults who did not require an interpreter. Effectiveness studies are needed to determine which interventions can help improve vaccination rates in the LEP population of elderly patients.
Keywords: elderly persons, immunizations, interpreter
Introduction
The US population is multicultural, multiracial, and multiethnic, with more than 500,000 refugees resettling in the country in the past decade (1). The number of older adults from the immigrant population is also growing. These elderly persons have multiple health care barriers such as limited English language proficiency (LEP) that may cause health care disparities. They have less access to care, lower rates of physician visits, more emergency department visits, and disparities on diabetes guidelines recommendations (hemoglobin A1c >8%, 66.9% vs 73.9%; P<.001) compared with patients who do not require interpreter services in the overall US population (2–7).
Since the 1960s, Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d) continues to be the most important legislation for providing LEP individuals a legal right to free language assistance services (8). In 2007, a systematic review showed that professional interpreters are associated with an overall improvement of care in the areas of communication, utilization of clinical services, clinical outcomes, and satisfaction for LEP patients compared with the use of ad hoc interpreters (9).
Among older adults, those who obtain preventive services and practice healthy behaviors are more likely to stay functionally independent (10). One important preventive service is vaccination against pneumococcus. Acute respiratory infections are the eighth leading cause of death in the United States, accounting for 56,000 deaths annually (11).
Vaccination against pneumococcus for adults age 65 years and older is associated with improved survival during hospitalization, decreased chance of respiratory failure, and a median length-of-stay reduction of 2 days for patients with community-acquired pneumonia compared with individuals who have no record of vaccination (12). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is cost-effective and potentially a cost-saving measure among older adults (13). The National Health Interview Survey from 1997 to 2015 showed that 68% of non-Hispanic white adults received a PPSV23, followed in frequency by 50% of non-Hispanic black adults and 41% of Hispanic adults (14).
National surveys and previous research on vaccination rates of older adults were based on data collection of self-reports, with no clinical verification (15). Self-report of receipt of a PPSV23 has high sensitivity (85%−95%) with relatively low specificity (46%−53%) compared with health record documentation (16, 17). These data results were obtained from a homogeneous younger population at the Veterans Health Administration medical centers with no LEP (16, 17). Despite this difference, the information contains a serious limitation that makes the data subject to biases such as volunteer bias and inaccurate recall, particularly since the vaccine schedule recommendations have changed recently.
The present study aimed to identify the association between vaccination rates of 13-valent pneumococcal conjugate vaccine (PCV13) and PPSV23 in older non–English language speakers who required the use of an interpreter during medical encounters compared with English speakers in a primary care population. For a secondary aim, we sought to identify the demographic factors that influenced the completion of vaccination in older non–English-speaking populations.
Methods
Study Design
We conducted a retrospective comparison of a population-nested matched cohort of non-English speakers age 65 years and older who required an interpreter with a referent group who did not require interpreter services. Health records were reviewed from January 1, 1980, through November 30, 2017, for patients who gave research authorization. The institutional review board approved the study. Authors followed the existing Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline for observational studies.
Study Setting and Participants
Eligible patients were adult residents age 65 years or older. Participants lived in the Southeastern area of our state with an assigned primary care provider in the Family Medicine and Primary Care Internal Medicine clinics of our institution’s Employee and Community Health (ECH). Patients were empaneled from June 1 through November 30, 2017. Inclusion criteria to the LEP group were prompted by an electronic alert designed to identify the need for an interpreter during medical encounters. This identification is self-reported at the time of the patient’s medical registration. Clinically, a patient either has an interpreter in the room, on video teleconference, or on the telephone during the clinical encounter. In some cases, a family member served as interpreter if requested by the patient. The language department of our institution employs interpreters and translators who provide communication assistance to non–English-speaking patients or LEP patients. Currently, 75 interpreters provide interpretation in 23 languages and go to more than 65,000 patient appointments yearly.
The usual care for all patients included frequent reminders about necessary preventive services available at the time of visits, through US mail or electronic communication on a secure Health Insurance Portability and Accountability Act–compliant patient portal. The primary care providers at our ECH are encouraged to complete national guidelines for age- and sex-specific preventive services with a reminder through a web-based application called Generic Disease Management System. This system is designed to show relevant patient information in an easy-to-consume format. In addition, specific protocols allow nurses to administer vaccines without a provider order if the patient meets inclusion criteria based on national guidelines.
Control patients were identified from the remaining cohort of consecutive patients. Patients were matched 1 to 1 to controls on the basis of age, sex, and Charlson comorbidity index. The referent controls were empaneled during the same time as the LEP population. Selection of matching variables was performed a priori with consideration of clinical and statistical factors.
Outcome Measures
Two outcome variables were assessed: PCV13 and PPSV23 rates. The use of PPSV23 has been routinely recommended since 1984 for adults older than or age 65 years and adults with high-risk conditions (18). These recommendations have been revised, and the current immunization schedule for adults age 19 years and older published in February 2017 dictates that immunocompetent adults age 65 years and older should receive PCV13, followed by PPSV23 at least 1 year after PCV13. If PPSV23 has been administered previously, PCV13 should be administered at least 1 year after PPSV23. No additional dose of PPSV23 is indicated for adults who received PPSV23 at age 65 years or older (19).
Demographic information, such as age, sex, race/ethnicity, primary language, marital status, education level, and Charlson comorbidity index, was abstracted automatically from the electronic health records. The records of patients from both groups were reviewed by 2 trained study investigators for accuracy of vaccination rates and confirmation of LEP status. Categories were created for marital status (married vs other), primary language (English, Somali, Vietnamese, Spanish, and other), and education level (eighth grade or less, high school graduate, and post high school studies). The categories were created on the basis of characteristics of both groups.
Analysis
Descriptive statistics were computed as frequency count and percentage for categorical variables and as mean and standard deviation for continuous variables. For continuous variables, t test was used, and means were reported. P<.05 was considered statistically significant. Categorical variables were created for primary language, marital status, race/ethnicity, and education level. Differences in vaccination rates between the LEP group and the referent group were compared with χ2 test.
For the secondary aim, variables were identified and analyzed with use of univariate logistic regression and a subset analysis of the LEP group with multivariate logistic regression. The adjusted effects were reported as odds ratio (OR) and 95% CI. All statistical analyses were performed with JMP Pro software (version 13.0; SAS Institute Inc).
Results
In total, 24,052 adult patients age 65 years and older were identified. Of these, 617 (2.6%) were identified as persons with LEP (Table 1). This group was matched with a referent control group of 617 patients. Approximately 41% of the patients were men. Age ranged from 65 to 97 years (mean [SD], 74 [7] years). More than one-half of patients (54%) in the LEP group were married compared with 68% in the control group. The majority of patients had government medical insurance (66% in LEP group and 82% in control group). One-third of patients in the LEP group had no medical insurance. The LEP group’s predominant primary language was Somali (24%), followed in frequency by Vietnamese (15%) and Spanish (13%). In this group, many patients (45%) had post high school studies; in the control group, 65% had this education level (Table 2).
Table 1.
Demographic Characteristics of Study Sample
| Valuea |
|||
|---|---|---|---|
| Characteristic | Patient LEP Group (n=617) | Control Group (n=617) | P Value |
| Age, mean (SD) (range), y | 74 (7) (65–97) | 74 (7) (65–97) | |
| Sex | |||
| Female | 365 (59) | 365 (59) | |
| Male | 252 (41) | 252 (41) | |
| CCI, mean (SD) (range) | 1.0 (1.56) (0–10) | 1.0 (1.56) (0–10) | |
| Marital status | <.001 | ||
| Married | 347 (56) | 422 (68) | |
| Otherb | 270 (44) | 195 (32) | |
| Education level | <.001 | ||
| Eighth grade or less | 248 (40) | 10 (2) | |
| High school graduate | 90 (15) | 204 (33) | |
| Post high school studies | 279 (45) | 403 (65) | |
| Primary language | <.001 | ||
| English | 617 (100) | ||
| Somali | 149 (24) | ||
| Vietnamese | 92 (15) | ||
| Spanish | 80 (13) | ||
| Otherc | 296 (48) | ||
| Race/ethnicity | <.001 | ||
| White | 85 (14) | 607 (98) | |
| Black/African American | 143 (23) | 1 (0.2) | |
| Asian | 235 (38) | 1 (0.2) | |
| Otherd | 154 (25) | 8 (1) | |
| Medical insurance | <.001 | ||
| Government | 409 (66) | 506 (82) | |
| Self-pay | 181 (29) | 73 (12) | |
| Othere | 27 (4) | 38 (7) | |
Abbreviations: CCI, Charlson comorbidity index; LEP, limited English language proficiency; max, maximum; min, minimum.
Values are presented as number (percentage) of patients unless specified otherwise.
Includes divorced, legally separated, single, and widowed marital status.
Includes Arabic, Bosnian, Cambodian, Dinka, Lao, Russian, Cantonese, Mandarin, Farsi, Greek, Hmong, Serbian, and Tagalog languages.
Includes American Indian/Alaskan Native and Caribbean race/ethnicity, among others.
Includes private and nongovernment insurance.
Table 2.
Predictors of Pneumococcal Vaccination Rate in the Patient Group With Limited English Language Proficiency
| Vaccination Schedulea (N=617) |
||||
|---|---|---|---|---|
| Characteristic | PCV13 Completed (n=386) | PCV13 Not Completed (n=231) | PPSV23 Completed (n=374) | PPSV23 Not Completed (n=243) |
| Age, mean (SD) (min, max), y | 74.2 (6.8) (65, 96) | 73.8 (7.3) (65, 97) | 76.5 (6.7) (65, 97) | 70.2 (5.5) (65, 93) |
| Sex | ||||
| Female | 220 (57) | 145 (63) | 223 (60) | 142 (58) |
| Male | 166 (43) | 86 (37) | 151 (40) | 101 (42) |
| CCI, mean (SD) (min, max) | 1.13 (1.43) (0, 10) | 0.84 (1.75) (0, 10) | 1.19 (1.62) (0, 10) | 0.76 (1.44) (0, 10) |
| Marital status | ||||
| Married | 222 (58) | 125 (54) | 205 (55) | 142 (58) |
| Otherb | 164 (42) | 106 (46) | 169 (45) | 101 (42) |
| Education level | ||||
| Eighth grade or less | 162 (42) | 86 (37) | 168 (45) | 80 (33) |
| High school graduate | 51 (13) | 39 (17) | 60 (16) | 30 (12) |
| Post high school studies | 173 (45) | 106 (46) | 146 (39) | 133 (55) |
| Primary language | ||||
| Somali | 76 (20) | 73 (32) | 93 (25) | 56 (23) |
| Vietnamese | 65 (17) | 27 (12) | 69 (18) | 23 (9) |
| Spanish | 48 (12) | 32 (14) | 40 (11) | 40 (16) |
| Otherc | 197 (51) | 99 (43) | 172 (46) | 124 (51) |
| Medical insurance | ||||
| Government | 311 (81) | 98 (42) | 272 (73) | 137 (56) |
| Self-pay | 54 (14) | 127 (55) | 88 (24) | 93 (38) |
| Otherd | 21 (5) | 6 (3) | 14 (4) | 13 (5) |
Abbreviations: CCI, Charlson comorbidity index; max, maximum; min, minimum; PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23, 23-valent pneumococcal polysaccharide vaccine.
Values are presented as number (percentage) of patients unless specified otherwise.
Includes divorced, legally separated, single, and widowed marital status.
Includes Arabic, Bosnian, Cambodian, Dinka, Lao, Russian, Cantonese, Mandarin, Farsi, Greek, Hmong, Serbian, and Tagalog languages.
Includes private and nongovernment insurance.
We observed a lower PCV13 vaccination rate for patients with LEP than patients without LEP (386 vs 479; OR [95% CI], 2.07 [1.61–2.66]; P<.001). In a similar manner, we found a lower PPSV23 vaccination rate for patients with LEP than the referent group (374 vs 464; OR [95% CI], 1.97 [1.54–2.51]; P<.001). Among the LEP adults, a subset multivariate analysis (Table 3) showed that patients with government medical insurance had a higher chance of PCV13 vaccination than patients with no medical insurance (P<.001). Furthermore, patients whose primary language was Somali had a lower chance of PCV13 vaccination than patients who spoke Vietnamese (P<.001) or other languages (P=.002). No differences were observed between patients who spoke Somali or spoke Spanish as their primary language.
Table 3.
Association Between Demographic Factors and Completion of Pneumococcal Vaccination in the Patient Group With Limited English Proficiency
| Characteristic | OR (95% CI) | P Value |
|---|---|---|
| PCV13 | ||
| Age per 10-y increase | 1.00 (0.77–1.31) | .95 |
| Sex | .05 | |
| Female | Reference | |
| Male | 1.49 (0.98–2.24) | |
| Education level | .16 | |
| Eighth grade or less | Reference | |
| High school graduate | 0.59 (0.33–2.96) | |
| Post high school studies | 0.99 (0.66–1.50) | |
| CCI per 1 U increase | 1.02 (0.90–1.16) | .65 |
| Language | <.001 | |
| Somali | Reference | |
| Spanish | 1.63 (0.86–3.06) | |
| Vietnamesea | 3.65 (1.89–7.02) | |
| Otherb | 2.02 (1.28–3.20) | |
| Marital status | .44 | |
| Married | Reference | |
| Otherc | 1.17 (0.77–1.76) | |
| Medical insurance | <.001 | |
| Government | Reference | |
| Self-pay | 0.12 (0.08–0.18) | |
| Otherd | 1.04 (0.39–2.77) | |
| PPSV23 | ||
| Age per 10-y increase | 6.84 (4.68–10.01) | <.001 |
| Sex | .41 | |
| Female | Reference | |
| Male | 0.84 (0.55–1.27) | |
| Education | <.001 | |
| Eighth grade or less | Reference | |
| High school graduate | 1.26 (0.69–2.29) | |
| Post high school studies | 2.44 (1.61–3.72) | |
| CCI per 1 U increase | 1.17 (1.03–1.33) | .009 |
| Language | .003 | |
| Somali | Reference | |
| Spanish | 0.72 (0.38–1.38) | |
| Vietnamesee | 2.39 (1.22–4.71) | |
| Otherb | 0.84 (0.52–1.37) | |
| Marital status | .53 | |
| Married | Reference | |
| Otherc | 0.87 (0.57–1.33) | |
| Medical insurance | .003 | |
| Government | Reference | |
| Self-pay | 0.48 (0.31–0.74) | |
| Otherd | 0.99 (0.40–2.42) | |
Abbreviations: CCI, Charlson comorbidity index; OR, odds ratio; PCV13, 13-valent pneumococcal conjugate vaccine; PPSV23, 23-valent pneumococcal polysaccharide vaccine.
Patients who spoke Vietnamese had a higher chance of receiving PCV13 than patients who spoke Spanish as their primary language (OR [95% CI], 0.44 [0.21– 0.94]; P=.03).
Includes Arabic, Bosnian, Cambodian, Dinka, Lao, Russian, Cantonese, Mandarin, Farsi, Greek, Hmong, Serbian, and Tagalog languages.
Includes divorced, legally separated, single, and widowed marital status.
Includes private and nongovernment insurance.
Patients who spoke Vietnamese had a higher chance of receiving PPSV23 than patients who spoke Spanish as their primary language (OR [95% CI], 0.30 [0.14–0.64]; P=.001) or spoke other languages (OR [95% CI], 0.35 [0.19–0.64]; P<.001).
The variables that had statistically significant association with higher chances of PPSV23 vaccination were older age (P<.001), higher Charlson comorbidity index (P=.009), having government medical insurance compared with no medical insurance (P<.001), and primary language (Table 3). The patients whose primary language was Somali had a lower chance of PPSV23 vaccination than patients who spoke Vietnamese (P<.01). Interestingly, patients with an education level of eighth grade or less had a higher chance of PPSV23 vaccination than patients with post high school studies (P<.001).
Discussion
In this population-based cohort study, older adults with LEP who required an interpreter during medical encounters were twice as likely not to receive vaccination with PPSV23 or PCV13 compared with English-speaking older adults. These results differ with previous reports of preventive services in the LEP population, where no significant difference was found in pneumococcal vaccination even after adjustment for age and sex (2). Another study showed lower rates of completed preventive services in patients of Hispanic descent who did not speak English at home (risk ratio, 0.84; 95% CI, 0.68–0.95) compared with English speakers (20). Thus, controversy still exists about the potential utilization of preventative services in groups with LEP. The present study found statistically significant differences in pneumococcal vaccination rates in this LEP population. The reduction of this major disparity continues to be a challenge, highlighting the urge for more studies and practice changes to help improve delivery of care to this older adult population.
Multiple factors may have an important role in the vaccination rates for the elderly population that uses an interpreter. A study in 2014 analyzed the 2012 National Health Interview Survey and found that age, sex, education, health insurance, usual place of care, and number of physician visits in the past 12 months were independently associated with receipt of most of the reviewed vaccines (21). Among US immigrants, the most prominent factor determining the utilization of a vaccine was the lack of health insurance (21). As expected, our results in the present study showed that patients with government medical insurance had higher chances of completing the pneumococcal vaccination schedule.
Patients with higher Charlson comorbidity index scores were more likely to have the PPSV23 vaccination. This result may reflect a greater likelihood for office health care visits. The 2012 National Health Interview Survey reported that more than 85% of US adults age 65 years and older had at least 1 encounter with a health care provider in the preceding 6 months and more than 93% within the preceding year (22). Given the opportunity for most eligible adults to receive the recommended pneumococcal vaccination, these data are consistent with previous findings of Morrison et al (2), in which patients who had at least 1 primary care visit in the previous year were more likely to complete preventive services.
In our study, patients who spoke Somali had lower chances of PCV13 and PPSV23 vaccination than patients with a different primary language. Older adults from a diverse ethnic and cultural background may have different notions of health and illness compared with older adults from a Western culture. Another possibility is that this population may not embrace the concept of preventive care. Such services may have been unavailable in their countries of origin or may not be congruent with their beliefs on health care (23).
To date, no information is available about the older Somali adult’s perceptions on immunizations. One previous study reported vaccine rates in a Somali community (24). In that study, vaccination rates decreased because either Somali residents had learned that the vaccine was associated with adverse effects or they knew someone with an adverse effect after a vaccination. In addition, Somali parents were likely to believe that vaccines caused autism (35% of Somali parents vs 8% of non-Somali parents).
The reduction of immunization disparities among older LEP adults continues to be a challenge. The clinic-based health care system may not be meeting the needs of this population despite the availability of interpreter services, indicating the necessity for changes in health care policy and clinical practice. Patients may benefit from community engagement and collaborations between public health officials, primary care providers, and the community in general. Community immunization programs at senior centers, older-adult residential communities, or faith communities might provide a better opportunity to improve vaccination rates.
Limitations
This study has limitations. The need for an interpreter and the primary language are limited by the self-reported nature and may not reflect all patients with language barriers. Regarding outcomes, patients could have been vaccinated in other facilities or at a retail pharmacy. The study participants are empaneled primary care patients, and the potential for external administration is minimized but not eliminated. LEP does not correlate with the level of health literacy, a potential bias that was not measured in our population.
We have limited information on migration rates, and therefore only actively empaneled patients were included. Among all age groups, the likelihood of persons moving within our state is actually the lowest among residents age 65 to 74 years, with only about 3% moving in the course of a year (25). Patients were from a single region and at a larger academic medical center with a well-established system of interpreter services. The LEP population in this setting may not reflect LEP persons from different regions of the world.
Conclusion
Patients with LEP face lower vaccination rates. Some of these rates are partially explained by communication barriers. The study results are suggestive that in a population-based, matched case-control study of older adults with similar characteristics at baseline, the patients who required an interpreter during medical encounters were less likely to be vaccinated with PCV13 and PPSV23 compared with older adults who did not require an interpreter.
Patient-clinician communication is complex. Our findings are suggestive that a need exists for studies to determine which interventions can ameliorate the vaccination gap.
Acknowledgments
This study received no outside funding.
We give special thanks to the Division of Community Internal Medicine at our institution for the supportive provision of a study coordinator. We also thank the Office of Health Disparities Research for its work in obtaining data from the health records. This publication was made possible by Clinical and Translational Science Awards Grant Number UL1 TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
Abbreviations
- ECH
Employee and Community Health
- LEP
limited English language proficiency
- OR
odds ratio
- PCV13
13-valent pneumococcal conjugate vaccine
- PPSV23
23-valent pneumococcal polysaccharide vaccine
Footnotes
Conflict of interest: None.
Publisher: To expedite proof approval, send proof via email to scipubs@mayo.edu.
Contributor Information
Maria Mendoza De la Garza, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Stephanie M. Quigg, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Silvana B. De Lorenzo, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
Darrell R. Schroeder, Division of Biomedical Statistics and Informatics (Mr Schroeder), Mayo Clinic, Rochester, Minnesota
Paul Y. Takahashi, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Data Availability
The data that support the findings of this study are available from the corresponding author (M.M.) on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author (M.M.) on reasonable request.