Gaps in Clinical Care and Research Inclusion for Families Speaking Languages Other Than English

According to the 2019 American Community Survey, 22% of the US population older than age 5 years speak languages other than English (LOE) at home, and 8% report speaking English less than “very well.”¹  Despite antidiscrimination language protections under Section 1557 of the Patient Protection and Affordable Care Act,²  children and families who prefer LOE for medical care encounter well-documented disparities in patient experience, care, and health outcomes, including increased odds of serious adverse events.^3–7 

In this issue of Hospital Pediatrics, Maletsky et al⁸  and Rojas et al⁹  provide additional context about language disparities that occur in the inpatient pediatric setting. Maletsky et al⁸  conducted qualitative interviews of Spanish-, Arabic-, Mandarin-, and Portuguese-speaking caregivers facilitated by video interpreters. They assessed communication experiences of caregivers speaking LOE with the medical team. Caregivers reported a range of experiences, including preference for in-person interpreters, concerns about interpreter quality, and critiques that physicians may speak too fast or allow inadequate time for complete interpretation. Suggestions from caregivers included ensuring that physicians take their time, speak slowly, use plain language instead of medical jargon, and use nonverbal communication cues. Using video interpreters in this study was both a strength, allowing the inclusion of multiple languages, and a limitation because medical interpreters may not have been familiar with research methodology such as qualitative interviewing. Although an ideal practice might be to conduct interviews primarily in the preferred language of participants, most qualitative research resultantly occurs only in English or Spanish.¹⁰  By leveraging video interpretation, this study addresses the feasibility gap for languages of lesser diffusion, for which bilingual research staff may not be available.

In their cross-sectional survey of pediatric residents, Rojas et al⁹  found that, although most pediatric residents felt comfortable with telephonic and in-person interpretation (82% and 91%, respectively), few had interpreted interactions with caregivers during prerounding and rounds (23% and 9%, respectively). In addition to the survey, the authors used a tracking tool to evaluate resident self-reported interpreter use during and after rounds and found that families speaking LOE had lower odds of caregiver presence on inpatient rounds (adjusted odds ratio, 0.2; 95% confidence interval, 0.1–0.6), lower odds of receiving any updates after rounds (adjusted odds ratio, 0.3; 95% confidence interval, 0.1–0.6), and intermittent use of interpreters for postrounds updates (53% of the time). Limitations of this study include a low survey response rate, single-center data, and potential recall and social desirability biases associated with self-report. Therefore, true disparities in communication between patients who speak LOE and English-speaking patients are likely even greater than reported in this study. Further multicenter and direct observational data examining disparities in caregiver presence, communication, and inpatient engagement with families who speak LOE are warranted.

Disparities in language access for hospitalized pediatric patients and families who speak LOE highlighted by both author groups are multifold. Maletsky et al⁸  found that caregivers who speak LOE benefit when both physicians and interpreters can communicate clearly and patiently. Rojas et al⁹  demonstrated that not only are interpreters underused at certain touchpoints (eg, after rounds), but there are fewer total touchpoints and opportunities for communication overall for patients speaking LOE. Previous studies have found communication barriers with other members of health teams, such as nursing and hospital support staff, including clinical assistants.^11,12  Both authors noted they did not analyze additional interactions with other hospital staff members, who may also have disparate communication practices for patients/families who speak LOE. Thus, for families speaking LOE, evaluations and improvements must occur across the continuum of inpatient care with both written and oral communication. Research must also use rigorous observational and multidisciplinary data from different care team members.

Improvements are needed to address disparities in language access in both clinical operations and research. Although more innovation is needed, there are promising practices in clinical care that, if implemented effectively, can improve communication, patient experience, and outcomes for individuals speaking LOE. For example, quality improvements that incorporate clinician education, instructional signage about how to access language services, and 1-touch dialing can improve rates of telephonic interpretation and optimize translation of discharge documents.^13,14  Additional improvements may include afternoon huddles for patients speaking LOE, increased use of video interpretation, and expanded interpreter roles in select circumstances to include cultural brokerage rather than solely literal interpretation.¹⁵ 

To improve health equity, generalizability of research findings, and trust in research, it is important to develop and promote standards of multilingual methodology. Multilingual recruitment and data collection should be required for all studies, not solely those focused on language barriers. A recent review of 3 major US pediatric journals found that in the past decade, only 9% of studies included non–English-speaking participants, and 82% had no mention of language.¹⁰  Promising practices in multilingual research from Maletsky et al⁸  and Rojas et al⁹  include incorporating language access experts into the study team, conducting interviews in the respondents’ preferred languages, including multiple languages, and receiving institutional support for interpreter use.^8,9  Moreover, support for development and funding of multilingual research best practices is needed. Such best practices may include incorporation of linguistic and cultural experts on research teams, methods to determine participants’ preferred language, and translating and culturally adapting study materials.

We support the call for language justice that was recently featured in Hospital Pediatrics,¹⁶  and this call must expand beyond hospital walls and reach across the spectrum of clinical care and research. Engaging multilingual patients and families as partners and participants in research has the potential to improve the quality, value, equity, and rigor of research and clinical care.