Changes in research on language barriers in health care since 2003: A cross-sectional review study☆
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.
References (41)
The impact of language barriers on the health care of Latinos in the United States: a review of the literature and guidelines for practice
J. Midwifery Womens Health
(2002)65 Fed. Reg 50121
(2000)68 Fed. Reg 47311
(2003)- et al.
Impact of English proficiency on care experiences in a pediatric emergency department
Acad. Pediatr.
(2014) Australia's Migration Trends-12 at a Glance
(2011)- et al.
Use and effectiveness of interpreters in an emergency department
JAMA
(1996) - Census Bureau. 2010 Census Data. Available at http://2010.census.gov/2010census/data. Accessed December 15,...
- et al.
The legal framework for language access in healthcare settings: title VI and beyond
J. Gen. Intern. Med.
(2007) - et al.
Primary language and receipt of recommended health care among Hispanics in the United States
J. Gen. Intern. Med.
(2007) - et al.
Are language barriers associated with serious medical events in hospitalized pediatric patients?
Pediatrics
(2005)
Getting by: underuse of interpreters by resident physicians
J. Gen. Intern. Med.
Labour migration patterns in Europe: recent trends
Future Challenges
Ethnic differences and similarities in outpatient treatment for depression in the Netherlands
Psychiatr. Serv.
Immigration and Ethnocultural Diversity in Canada
National Standard Guide for Community Interpreting Services
Language Barriers In Health Care Settings: An Annotated Bibliography of the Research Literature
The need for more research on language barriers in health care: a proposed research agenda
Milbank Q.
Responding to the language challenge: Kaiser permanente's approach
Permanente J.
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For the Policy and Research Committee of the National Council on Interpreting in Health Care (NCIHC).