Changes in research on language barriers in health care since 2003: A cross-sectional review study

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Abstract

Background

Understanding how to mitigate language barriers is becoming increasingly important for health care providers around the world. Language barriers adversely affect patients in their access to health services; comprehension and adherence; quality of care; and patient and provider satisfaction. In 2003, the United States (US) government made a major change in national policy guidance that significantly affected limited English proficient patients’ ability to access language services.

Objective

The objectives of this paper are to describe the state of the language barriers literature inside and outside the US since 2003 and to compare the research that was conducted before and after a national policy change occurred in the US. We hypothesize that language barrier research would increase inside and outside the US but that the increase in research would be larger inside the US in response to this national policy change.

Methods

We reviewed the research literature on language barriers in health care and conducted a cross sectional analysis by tabulating frequencies for geographic location, language group, methodology, research focus and specialty and compared the literature before and after 2003.

Results

Our sample included 136 studies prior to 2003 and 426 studies from 2003 to 2010. In the 2003–2010 time period there was a new interest in studying the providers’ perspective instead of or in addition to the patients’ perspective. The methods remained similar between periods with greater than 60% of studies being descriptive and 12% being interventions.

Conclusions

There was an increase in research on language barriers inside and outside the US and we believe this was larger due to the change in the national policy. We suggest that researchers worldwide should move away from simply documenting the existence of language barriers and should begin to focus their research on documenting how language concordant care influences patient outcomes, providing evidence for interventions that mitigate language barriers, and evaluating the cost effectiveness of providing language concordant care to patients with language barriers. We think this is possible if funding agencies around the world begin to request proposals for these types of research studies. Together, we can begin document meaningful ways to provide high quality health care to patients with language barriers.

Introduction

There is a law in the United States, Title VI of the Civil Rights Act of 1964, that requires all federally funded programs to provide meaningful access to care for limited English proficient (LEP) individuals (Lau et al. 1974). Despite the federal right to meaningful access to language services for LEP patients in federally funded programs, the reality is that many health care providers are not providing adequate services to their LEP populations (Chen et al., 2007). This is because it is not widely enforced and health care providers have little understanding of how to comply with it. To increase awareness of the law and to provide explicit guidance as to how health care organizations could comply with the law, President Clinton issued Executive Order (EO) 13166 in August, 2000, Improving Access to Services for Persons with Limited English Proficiency (August 16, 2000). Some health care providers and professional organizations took issue with this guidance, calling it an “unfunded mandate” (Neighborhood Health Plan of Rhode Island, in press), and in response, the Bush Administration revised and reissued the Policy Guidance soon after taking office (August 8, 2003). This reversal in provision of explicit guidance by the Bush Administration brought publicity to the issue of language barriers in health care and the impact they potentially have on care (Meyers et al., 2009, National Council on Interpreting in Health Care, 2011). We hypothesized that this policy debate and the surrounding publicity galvanized the research community in the US to increase their investigation of language barriers in health care, how to overcome them, how they impact care, and interventions to reduce them, and that this increase would not occur to the same degree outside the US. We undertook this study to describe the state of language barriers research inside and outside the US from 2003 to 2010 and to descriptively compare the research that occurred before and after this national policy change.

Countries around the globe welcome and/or absorb immigrants. In Europe, Canada, and Australia, for example, there have been growing numbers of immigrants and patients who do not speak the language(s) used in their health care systems (Australian Government, 2011; Somerville, 2009, Taylor, 2012, Young, 2013). Over the last decade in the UK, there have been growing numbers of immigrants, and they are coming from more diverse backgrounds than ever before (Somerville, 2009). In Canada, although the number of immigrants has remained relatively constant; the countries they come from have shifted (Government of Canada, 2011). Currently, the largest percentage of immigrants come from Asia (including the Middle East) as compared to European immigrants which made up the majority of Canadian immigrants up until the 1970s (Government of Canada, 2011). In Australia, migration continues to be the major component of population growth with almost half of Australia's population either born overseas or with a migrant parent (Australian Government).

Language barriers significantly affect quality of care in the health care system around the world (Fassaert et al., 2010, Murray et al., 2010, Ou et al., 2010, Ponce et al., 2006, Poureslami et al., 2010, Puthussery et al., 2010, Sokal, 2010, Timmins, 2002). Research suggests that language barriers adversely affect patients in their access to health services (Jacobs et al., 2006, Pippins et al., 2007, Robert Wood Johnson Foundation, 2001); comprehension and adherence (Cheng et al., 2007, Jacobs et al., 2006); quality of care (Cohen et al., 2005, Diamond et al., 2009, Jacobs et al., 2003, Jacobs et al., 2006); and patient and provider satisfaction. (Arthur et al., 2014, Baker et al., 1996, Jacobs et al., 2006)

Language barriers are also a big issue in the US as they affect a growing portion of the population there as well. The number of limited English proficient (LEP) individuals in the US increased by 80 percent between 1990 and 2010 (Pandya et al., 2011) and, according to the 2010 US census, 25.2 million people or nine percent of the US population over the age of five is LEP (Pandya et al., 2011). Given this large and growing population in the United States, US Federal Policy around language barriers in health care, and the significant publicity and debate around a change in policy guidance in 2003, we had the opportunity to study whether or not this impacted the quantity and type of language barriers research.

While the analysis focused on a policy change in the US, this work is relevant to a global audience because it provides a broad summary of the state of language barriers research around the world and is a case study of how a policy change in the US did or did not impact the trajectory of language barriers research. Policy makers in other countries likely will be interested to see if national policies influence the research community and if so, in what ways.

The aims of this work are (1) to describe the state of the language barriers literature inside and outside the US from 2003 to 2010 and (2) to compare the research that was conducted before and after the national policy change. A comprehensive annotated bibliography describing the state of the language barriers literature was published in 2003 (Jacobs et al., 2003), but to our knowledge no comprehensive description of the state of the language barriers research across all specialties has been conducted since that time. We hypothesized that research on language barriers would dramatically increase after 2003, and the focus of the research would shift from documentation of language barriers as a risk for disparities in health care to evidence that interventions improved care. We included studies conducted outside the US to show how the language barriers literature evolved independent of the national policy change that occurred in the US. We hypothesized that we would see more of a pronounced increase in studies and change in methodology within the US compared with outside the US as a result of the national policy change in the US.

Section snippets

Review

We reviewed the literature focusing on language barriers and health from 1975 to 2010 in two steps and then conducted a cross sectional analysis of the type and distribution of manuscripts in the literature that were published before and after the policy change in 2003.

First, we completed a review of the literature in 2003 for an annotated bibliography entitled Language Barriers in Health Care Settings: An Annotated Bibliography of the Research Literature, commissioned by The California

Results

One hundred thirty six published studies met our inclusion criterion in the pre-2003 period and 426 studies in the 2003–2010 period (Appendix 3). The percent of published peer-reviewed studies in the 2003–2010 period increased by 326% in the US and by 292% outside the US. Researchers in the US continued to publish the majority of the research on language barriers in the 2003–2010 period (Table 1). Outside of the US, Australia, Canada and the United Kingdom also continued to conduct the most

Discussion

A substantial amount of research on language barriers in the health care setting was done inside and outside the US in the 2003–2010 time period and this represented an increase from our initial review from 1974 to 2003. The majority of this more recent research focused on access barriers, comparison studies, interpreting practices, outcomes and patient satisfaction. It was descriptive in nature and most of the research conducted in the US focused on Spanish-language research.

As hypothesized,

Conflict of interest

The authors have no conflicts of interest to declare.

Funding

This work would not have been possible without the support of National Council on Interpreting in Health Care (NCIHC), a multidisciplinary organization whose mission is to promote and enhance language access in health care in the United States. Support was provided by the Departments of Medicine and data storage and analytic software was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant

Ethical approval

No human subjects were involved in this research.

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