The Journal of Pediatrics
Volume 148, Issue 2 , Pages 154-157, February 2006

Lost in translation? pediatric preventive care and language barriers

  • Glenn Flores, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Glenn Flores, MD, Center for the Advancement of Underserved Children, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226

Center for the Advancement of Underserved Children, Departments of Pediatrics and Epidemiology, Medical College of Wisconsin, Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226

Article Outline

Abbreviations:  LEP, Limited English proficiency , SCHIP, State Children’s Health Insurance Program

 

There are 47 million people in the United States who speak a language other than English at home; equivalent to almost 1 in 5 Americans. In 2003, 19% of school-age children spoke a language other than English at home, almost triple the number of that reported in 1979.2 Almost 1/2 of all Americans3 and U.S. schoolchildren2 who speak a non-English language at home are limited in English proficiency (LEP), defined as having a self-rated ability to speak English less than “very well.”

Studies document that language barriers can have numerous detrimental consequences for children’s health, including suboptimal health status, impaired access to medical care, lower likelihood of having a usual source of care, increased risk of intubation in patients with asthma, higher resource utilization for diagnostic testing, lower quality of care, and compromised patient safety.4, 5, 6 Although language barriers have been associated with reduced preventive services in adults,7, 8, 9 previous research has not examined the impact of language barriers on preventive services in children.

In this issue of The Journal, Cohen and Christakis 10 report the results of the first published study to examine disparities in recommended pediatric preventive care visits based on parental primary language. The strengths of this population-based, retrospective cohort study include the large sample size (n = 38,793) and analysis of data on all infants born in Washington state over a 21-month period who were continuously enrolled in Medicaid. The authors found that all 6 recommended preventive care visits in the first year of life were made by 17% of infants whose primary language was English, compared with only 8% of infants whose parents’ primary language was not English. In addition, infants whose parents primary language was not English had half the adjusted relative risk of making all 6 recommended preventive visits compared with infants whose parents’ primary language is English. Therefore, this study reveals that primary care is inadequate for 11 of 12 Medicaid-covered infants whose parents’ primary language is not English.

These findings are of concern for several reasons. The available evidence indicates that several interventions occurring during well-child care visits in the first year of an infant’s life are associated with positive health processes and outcomes, including greater use of car seats and smoke alarms, safer tap water temperatures, reduced exposure to passive smoking, increased initiation of breast-feeding, less amblyopia, better visual acuity, and reduced iron-deficiency anemia.11 Having an adequate number of well-child visits is associated with a significantly greater likelihood of being up to date on immunizations,12 a lower risk of emergency department visits,13 and a lower likelihood of certain avoidable hospitalizations.14 Benefits of adequate primary care also include greater access to needed services, better quality of care, greater focus on prevention, earlier management of health problems, more appropriate care, and reduced unnecessary and potentially harmful specialist care.15 For infants whose parents’ primary language is not English, this disparity in preventive care places these infants at high risk for impaired access to care, suboptimal health status, and adverse health outcomes.

Why is it that infants whose parents’ primary language is not English experience disparities in preventive care? This question could not be addressed in the Cohen and Christakis study, as often is the case with secondary dataset analyses. But recent research16 may shed light on the potential causes. After multivariate adjustment for relevant covariates, parental LEP is associated with significantly greater odds of a child not being brought in for needed medical care due to the parents’ difficulty in making appointments with the child’s care provider.16 This finding suggests that the disparity in infants’ preventive care visits may simply be a function of the substantially greater challenges of making appointments faced by parents whose primary language is not English. Barriers to making pediatric appointments for LEP parents include lack of bilingual staff at the clinic front desk, monolingual English telephone receptionists and telephone message systems, unavailability of interpreters (in person or via telephone) when appointments are being made, inadequate multilingual signage at clinics, and monolingual English appointment reminders. The children of LEP parents also have more than 4 times the adjusted odds of not being brought in for care due to the medical staff not understanding the family’s culture,16 highlighting the importance of culturally competent care. Transportation difficulties and inaccessible health care facilities also were associated with significantly greater adjusted odds of LEP parents not bringing children in for needed care. Finally, even after adjustment for 11 covariates, including insurance coverage and family income, LEP parents had double the odds of not bringing in their child for needed care due to inability to afford medical care. This finding may indicate that the trend toward families bearing the burden of greater copayments for medications and health care provider visits may be having a deleterious impact on the delivery of adequate pediatric primary care, particularly for Medicaid-covered children in low-income families.

Another important contribution of the study by Cohen and Christakis is that it underscores the important but frequently overlooked health care disparities that exist for families encountering language barriers. For example, recent analyses of the National Survey of Early Childhood Health17, 18 reveal that, compared with young children with parents surveyed in English, young children with parents surveyed in a language other than English had significantly greater adjusted odds of being uninsured, of having suboptimal health status, of not being referred to specialists, of having parents make fewer telephone calls to doctors’ offices, of encountering clinicians who never or only sometimes understands the child’s specific needs, of parents not putting stoppers or plugs in electrical outlets, of parents never reading to the child, and of having fewer children’s books in the household. Similar findings have been noted for children with special health care needs who have LEP parents.19 Speaking a language other than English at home is associated with a number of adverse consequences for adolescents, including not wearing seatbelts and bicycle helmets, being alienated from classmates, being bullied, and other psychosocial and school-related risk factors.20, 21

The study by Cohen and Christakis raises several issues that merit further research. Parental LEP has been shown to be superior to the primary language spoken at home as a measure of the impact of language barriers on children’s health, use of health services, and access to care16; thus, an analysis of the association between parental LEP and pediatric preventive care visits is needed. Addressing this issue remains a far too formidable challenge, however, because few federal, state, or health plan databases collect information on the primary language spoken at home or LEP. For example, a recent evaluation of 80 federal program–specific statutes that require reporting or collection of data found that none mention primary language data.22 The findings of the Cohen and Christakis study were not adjusted for parental citizenship status, parental duration of residency in the United States, parental educational attainment, use of interpreters, number of siblings, or whether the pediatric provider was bilingual; future work should integrate these key covariates into primary data analyses of the interrelationship of language barriers and pediatric preventive care visits. Further investigation is needed into why no disparity was observed for Asian Americans. There ostensibly should be no disparities for LEP patients covered by Medicaid in the state of Washington, because Washington is one of 12 states that provide third-party payer reimbursement (through Medicaid and the State Children’s Health Insurance Program [SCHIP]) for medical interpreter services.23, 24 Greater insight is needed into why disparities persist for Medicaid-covered LEP patients in a state providing excellent access to interpreters. Are there problems with interpreter services reimbursement, use of interpreters by health care providers, or the efficiency of appointment scheduling for LEP patients? Regardless of the primary language spoken at home, a serious concern is that only 1 in 6 Medicaid-covered children received all 6 recommended preventive visits. Studies are urgently needed to identify the reasons for this unacceptably low rate.

What can the pediatric clinician do to eliminate the disparity in preventive care visits for children in families whose primary language is not English? First, the clinician should ensure that LEP children and their families receive adequate interpreter services through trained medical interpreters, telephonic services, or bilingual clinicians. This guarantees compliance with federal laws and guidelines25, 26 requiring that all health care providers who receive federal funding (including Medicaid and SCHIP) provide meaningful access to LEP patients. In addition, a recent study in adults revealed that providing appropriate language services significantly increases office visits for preventive care.27 Second, the clinician should continuously monitor for such disparities by routinely collecting and monitoring practice data on the primary language spoken at home and parental English proficiency. (I would suggest using the U.S. Census data questions, which can be downloaded from the web.1) And third, the clinician should make sure that the pediatric office is conducive to scheduling and maintaining well-child care visits. Helpful measures in this regard include multilingual telephone personnel, answering machines, and phone trees; availability of trained medical interpreters, telephone interpretation services, or bilingual clinicians (who remain available after the visit to assist with scheduling appointments); multilingual signage (especially those directing patients to appointment-scheduling desks); translated printed patient information about the importance of well-child care visits; culturally competent staff; and multilingual reminder systems for upcoming appointments.

The Cohen and Christakis study has key policy implications. The disparity that these authors documented could substantially worsen due to recent policy changes in Washington’s Medicaid reimbursement for interpreter services. In 2003, the state Medicaid program reduced interpreters’ hourly pay and ceased direct contracting through interpreter agencies, switching to the administratively more cumbersome use of independent brokers.28 Concerns have been raised about these changes possibly disrupting patient continuity with interpreters and causing fewer patients to receive interpreters, as evidenced by the 15% drop in state-paid medical interpreter encounters between 2001 and 2004.28 The disparity documented in Washington may be even more pronounced elsewhere in the United States, particularly in the 37 states without Medicaid/SCHIP reimbursement for interpreters; the study findings thus indicate that states should consider monitoring for and addressing such disparities for their LEP patients. Finally, the scientific evidence suggests that it may prove more costly for state Medicaid programs to ignore such disparities for children whose parents’ primary language is not English. Appropriate pediatric preventive care has been shown to result in higher immunization rates,12 greater use of car seats and smoke alarms, safer tap water temperatures,11 and reductions in emergency department visits,13 avoidable hospitalizations,14 amblyopia,11 and iron-deficiency anemia,11 and thus deficiencies in relatively inexpensive preventive care visits could potentially translate into increased childhood morbidity, injuries, disability, costs of care, and mortality.

See related article, p. 254.

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References 

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PII: S0022-3476(05)01119-4

doi:10.1016/j.jpeds.2005.11.029

Refers to article:

  • Primary language of parent is associated with disparities in pediatric preventive care

    Adam L. Cohen, Dimitri A. Christakis
    The Journal of Pediatrics February 2006 (Vol. 148, Issue 2, Pages 254-258)

The Journal of Pediatrics
Volume 148, Issue 2 , Pages 154-157, February 2006

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