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Effect of the English language barrier on receiving quality healthcare for low English proficiency Latinos in the rural south

 

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Introduction

Low English proficiency or LEP Latinos, many of which are recent and first generation immigrants or migrant farmworkers, are those who have a limited ability to communicate in English. LEP Latinos represent an increasing constituency of individuals in rural southern communities, which means it is increasingly important for rural healthcare systems to staff clinicians that are able to speak Spanish in order to bridge the English language barrier and provide quality medical care for this growing population. However, the language and medical care needs of many LEP Latino patients within rural southern healthcare systems are not being met, primarily due to a shortage of bilingual clinicians that has roots in the lack of investment in and resources of rural health clinics. Interviews of Ysaura Rodriguez, Claudia Garrett, and Maria Torres from the Southern Oral History Program (SOHP) and external scholarly articles from rural health, medicine, and public health journals provide insights about the impact that the English language barrier has on receiving quality healthcare for LEP Latino individuals, how the English language barrier in rural healthcare is informed by difficulties in recruiting diverse staff to serve in rural health clinics, and in what ways language concordant and culturally competent medical care providers can improve the quality of care of LEP Latino patients.

How does the English language barrier affect the quality of healthcare of LEP Latino patients?

In her SOHP interview, retired migrant farmworker Ysaura Rodriguez remembers the time her young son was hospitalized with a stomach infection. At the hospital he was taken to, Rodriguez didn’t remember any of the doctors being able to speak Spanish. Though some of the nurses did, they were not always available to interpret when she needed them. She also describes the stresses of communicating with her son’s doctors due to the language barrier between them: “that was a bad experience… It was kind of difficult because I didn’t know much English… what I didn’t know, I made it up… I made them understand what I was saying somehow.1” As an LEP individual, Rodriguez experienced language discordance with her son’s doctors. Language discordance is defined as when a patient and their provider are not proficient in the same language, and has been linked to a variety of negative effects in patient and provider interactions, including fewer elicited concerns of patients and explained test results by doctors, in addition to less clear communication, respectful and compassionate interactions, and shared decision making between LEP Latino patients and rural clinic providers2. That same 2014 study found that less than half of LEP Latino patients who experienced language discordant communication had positive outcomes in those five interpersonal care metrics, with as low as 20% saying that they were able to make shared decisions with their provider2. Without a care provider or interpreter who can speak Spanish, LEP Latino patients often experience inadequate and disappointing instances of medical care in rural clinics3. These negative experiences can foster mistrust in clinicians and avoidance of the healthcare system4 by LEP Latinos, which can have adverse long term health effects of its own. Some Latinos may avoid healthcare services when they are needed, drawing on ineffective communication and care outcomes as reasons to not seek medical advice or treatment4.

How is the English language barrier in rural healthcare influenced by difficulties in recruiting diverse staff to serve in rural health clinics?

In rural clinics especially, the English language barrier is more difficult to overcome because of a decreased presence of interpretation services and bilingual staff. The lower pay and geographic inconvenience that comes with working at rural health clinics5 is less appealing to doctors, many of which already chose to work where they did their residency, 99% of which are located in urban and suburban areas6. As a result, rural health clinics often struggle to recruit diverse staff who are bilingual or able to interpret, especially when competing with urban facilities and private practices who can pay more and where doctors have more experience and familiarity working in6. Overall, the lack of Spanish interpreters and Spanish speaking clinicians in medical appointments of LEP Latinos has negative impacts on the quality of care of LEP Latino patients due to decreased communication, mutual respect, and decision making as a result of the English language barrier. This status is exacerbated in rural areas due to the difficulty of rural clinics in attracting diverse staff and is a primary factor that reduces quality healthcare for LEP Latinos in the rural southern US.

In what ways do language concordant and culturally competent medical care providers’ effect the quality of care of LEP Latino patients?

In light of Spanish-speaking clinician shortages in rural clinics and the adverse effects this shortage can have on the health experiences and outcomes of LEP Latino patients, it is essential to emphasize the importance of Spanish speaking staff in the care of LEP Latino patients and their role in bridging the English language barrier that is a major contribution to sentiments and experiences of mistrust, mistreatment, and avoidance that Latinos can harbor towards healthcare services in the United States. The CommWell Health clinic in Newton Grove, North Carolina serves many migrant farmworkers and is an example of a rural clinic that values and prioritizes Spanish language services for its patients, many of which are LEP Latinos. In many ways, it can serve as a blueprint for other rural health clinics and help increase clinicians’ interest in the important and rewarding role of serving LEP Latino patients. Many of the clinic’s staff are Latina themselves, and so in addition to being able to speak Spanish, they also demonstrate cultural competence, which is the ability to understand the cultural values, beliefs, and lifestyles of their patients in order to provide tailored healthcare based on cultural understanding that meets each patient’s unique needs7. Claudia Garrett, a former migrant farmworker and current health coach and Spanish interpreter at CommWell Health, reports that migrant farmworker patients at the clinic “feel welcomed… [and] like they are important because we have so much staff that speaks their language.8” Garrett understands the unique cultural backgrounds, values, and challenges facing the migrant farmworker patients she interprets for, and knows how important bridging the language barrier is in making LEP Latino patients feel valued and receive the quality of care they need. Maria Torres, who works as a certified nurse aide interpreter also at CommWell Health, further explains the important role that Spanish speaking clinicians have on positive health and social outcomes in medical environments for LEP Latino patients. Describing how interactions differ with her presence as a Spanish speaker in addition to the primary doctor or nurse in the room, she says that patients “feel more comfortable saying stuff whenever an interpreter is in there because they can really get all their problems out on the table and get them all resolved or fixed.9” She also explains that she feels “the interpreter’s job is really necessary every day,” and that “if there wasn’t an interpreter there in the room that it would be really hard for the patient to get the complete amount of care that they need.9” Interpreters like Garrett and Torres are shining examples of how language concordant and culturally competent providers improve the interpersonal nature and quality of care for LEP Latinos in rural healthcare systems. Both cultural competence and language concordance are essential for establishing efficient communication10, shared decision making, mutual respect, trust11, and compassion between doctors and patients2. Because of improved communication and interpersonal rapport with culturally competent and language concordant clinicians, adherence to medical treatment plans and receptivity to health advice of LEP Latino patients is also increased and can additionally lead to improved health outcomes2.

Conclusion

Though there is a systemic and pervasive language barrier currently preventing LEP Latino populations in the rural American south from receiving quality healthcare, clinicians like Claudia Garrett and Maria Torres are experts in how language concordance and cultural competence can greatly increase positive medical experiences of LEP Latino patients, and we can learn from these women in order to make great inroads in benefitting this underserved and essential population in the United States.

References

  1. Southern Oral History Program. “Y-0044 Ysaura Rodriguez :: Southern Oral History Program Interview Database.” Southern Oral History Program, 29 June 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28242/rec/1. Accessed 24 Apr. 2024.
  2. Detz, Alissa, et al. “Language Concordance, Interpersonal Care, and Diabetes Self-Care in Rural Latino Patients.” Journal of General Internal Medicine, vol. 29, no. 12, 3 Sept. 2014, pp. 1650–1656, https://doi.org/10.1007/s11606-014-3006-7.
  3. Blewett, Lynn A., et al. “Health Care Needs of the Growing Latino Population in Rural America: Focus Group Findings in One Midwestern State.” The Journal of Rural Health, vol. 19, no. 1, Dec. 2003, pp. 33–41, https://doi.org/10.1111/j.1748-0361.2003.tb00539.x.
  4. Twersky, Sylvia E, et al. “The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review.” Healthcare, vol. 12, no. 3, 31 Jan. 2024, pp. 364–364, https://doi.org/10.3390/healthcare12030364.
  5. Leider, Jonathon P., et al. “The State of Rural Public Health: Enduring Needs in a New Decade.” American Journal of Public Health, vol. 110, no. 9, Sept. 2020, pp. 1283–1290, https://doi.org/10.2105/ajph.2020.305728.
  6. Nielsen, Marci, et al. “Addressing Rural Health Challenges Head On.” Missouri Medicine, vol. 114, no. 5, 2019, pp. 363–366, www.ncbi.nlm.nih.gov/pmc/articles/PMC6140198/.
  7. Betancourt, J. R. “Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care.” Public Health Reports, vol. 118, no. 4, 1 July 2003, pp. 293–302, www.ncbi.nlm.nih.gov/pmc/articles/PMC1497553/pdf/12815076.pdf, https://doi.org/10.1093/phr/118.4.293.
  8. Southern Oral History Program. “Y-0023 Claudia Garrett :: Southern Oral History Program Interview Database.” Southern Oral History Program, 25 June 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28355/rec/80. Accessed 24 Apr. 2024.
  9. Southern Oral History Program. “Y-0056 Maria Torres :: Southern Oral History Program Interview Database.” Southern Oral History Program, 25 June 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28364/rec/74. Accessed 24 Apr. 2024.
  10. Molina, Rose L., and Jennifer Kasper. “The Power of Language-Concordant Care: A Call to Action for Medical Schools.” BMC Medical Education, vol. 19, no. 1, 6 Nov. 2019, bmcmededuc.biomedcentral.com/articles/10.1186/s12909-019-1807-4, https://doi.org/10.1186/s12909-019-1807-4.
  11. Harvey, S. Marie, et al. “Listening to Immigrant Latino Men in Rural Oregon.” American Journal of Men’s Health, vol. 7, no. 2, 17 Oct. 2012, pp. 142–154, https://doi.org/10.1177/1557988312463600. Accessed 25 Nov. 2019.
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