Equity Is Multilingual: A Call for Language Justice in Pediatric Hospital Medicine Free

In this issue of Hospital Pediatrics, Rajbhandari et al¹  report their findings from a national sample of hospitalists, demonstrating that use of interpreters in formal inpatient communication processes such as family-centered rounds and discharge planning remains low despite the availability of interpreter services in multiple modalities (phone, video, in-person). The study highlights several gaps in access to language services including availability of translation services, written materials in languages other than English (LOE), workflows designed around English-speaking patients, lack of access to American Sign Language interpreters, and quality of interpretation. If these gaps are not addressed, we will continue to observe worse outcomes for hospitalized children and families who use LOE compared with children and families who use English for communication.^2,3  Indeed, if families cannot communicate with us, how could we possibly be delivering quality care?

An often-overlooked dimension of health equity is language justice. Language justice is the creation and maintenance of spaces where all voices are heard and valued, including voices that are often marginalized, such as those of individuals of color, individuals who do not speak English, and individuals who do not speak English in ways that are more likely to be deemed socially acceptable.⁴  As hospitalists and inpatient providers based in the United States, most of us practice in a setting that distinctly centers around English in both written and verbal forms of communication. The centering of English is readily apparent in the default language of the cafeteria menu, hospital signage, family-centered rounds, and the informal discussions between staff when families and children are present. Each of these examples represents a statement of which language is the language of power and, alternatively, each of these examples represents an opportunity to communicate inclusivity and shared respect for diversity. Language justice is not a utopian ideal;, studies have shown that the lack of free communication between patients, families, providers, and staff leads to a higher risk of decompensation during hospitalization, misdiagnosis, readmission, medication errors and up to $20 000 more in hospital costs.^2,5,6 

Rajbhandari et al¹  show that most hospitalists are likely familiar with and have access to interpreter and translation services for individuals who speak LOE. However, these services are underused, primarily because of concerns about the amount of time required to access the services. Current provider workflows operate under the assumption that patients and families will speak English. Thus, when a family uses another language, providers are tasked with additional steps and have to deviate from their usual practice. This is a setup for noncompliance. When a patient or family requests services in a LOE, there should be processes that ensure interpreter presence and availability, especially for key portions of an inpatient stay including admission, rounds, and discharge. Making interpreter and translation services part of hospital culture, an expectation modeled by all providers, is another strategy that may increase the use of interpreter and translation services. At the policy level, insurer reimbursement for interpreter and translation services may render these services more widely accessible and increase the quality of services hospitals can provide.⁷ 

Rajbhandari et al¹  also found the failure to identify families who may need interpreter services as a key barrier to providing appropriate linguistic services. This aligns with prior research, showing that the need for linguistic services is often established far too late, sometimes after multiple conversations have taken place between providers, staff, and the patient and family. Proposed solutions include asking about language preference during patient registration and electronic medical record flags to indicate patients’ language preferences. However, these solutions still appear to leave a gap. In our current system, providers decide when and how to use an interpreter, leaving families with little control over preferred modality, timing, frequency, and use of interpreters. Given the current system, many families who use an LOE do not feel empowered to request an interpreter to ask questions, including both biomedical and logistical or self-care issues that may arise. Another solution may be to empower families to self-identify their language preferences; this could include using a patient-operated screen or tablet in the room to digitally indicate language preference or using community outreach and culturally concordant patient ambassadors to encourage families to request interpretation and translation as part of their right to optimal care. Patient- and family-facing tools can also be used to provide families with a resource to access an interpreter when and how they feel it is needed. Patient-facing tools not only empower patients/families but may also decrease the perceived “burden” of requesting an interpreter on the medical team.

The second most widely spoken language in the United States is Spanish. And although language justice for Spanish-speaking individuals is far from ideal, in many places access to interpreter and translation services for individuals who use languages other than Spanish or English may be minimal or nonexistent. There is a particularly notable gap in access to American Sign Language services.⁸  This emphasizes that the concept of language justice is more than just access to services, but rather creating a space where all voices can be heard and expressed. Additionally, the quality of communication in interpreter-supported encounters may not the same as for English-speaking and white families. Not only is there inconsistency in team practices in the structure of interpreter-supported rounds but patients and families who use LOE may receive less respect and partnership because of intersectional biases.^9,10  Last, interpretation is not a word for word translation from 1 language to another, and information is often filtered during interpretation, including loss of patient-centered communication.¹⁰  Thus, in addition to access to interpretation in both verbal and visual language, language justice includes standardizing interpreter-supported communication and fostering provider cultural and structural humility.

It is notable that Rajbhandri et al surveyed only pediatric hospitalists who were members of an academic research network, 40% of which were bilingual. This study does not describe the access to and use of interpreter services in the remainder of the interdisciplinary team, including nurses, resident physicians, and ancillary staff. Access and use of interpreter and translation services may be even lower in a more nationally representative sample inclusive of pediatric inpatient providers and hospital staff.

Each time a member of the medical team goes into the room of a patient who speaks an LOE without an interpreter, it effectively silences that family. Rajbhandri et al’s article¹  is an urgent call to develop and test strategies that promote language justice in pediatric hospital medicine and by doing so take an important step toward equitable health outcomes for all children.